Complete Drug List (Formulary) 2021€¦ · (Formulary) 2021 Medica HealthCare Plans MedicareMax...

Complete Drug List(Formulary) 2021

Medica HealthCare Plans MedicareMax Plus (HMO D-SNP)

Important Notes: This document has information about the drugs covered by this plan. For more

up-to-date information or if you have any questions, please call Customer Service at:

Toll-free 1-800-407-9069, TTY 7118 a.m. - 8 p.m. local time, 7 days a week

www.Medicaplans.com

Formulary ID Number 00021056, Version 9Last updated September 1, 2020Y0066_200707_124536_C v117.00

Table Of Contents

What is a drug list?......................................................................................................................................3

Note to existing members:......................................................................................................................... 3

How do I use the drug list?.........................................................................................................................4

What are generic drugs?............................................................................................................................ 4

What is a compounded drug?....................................................................................................................4

Drug payment stage and drug tiers...........................................................................................................5

Getting Extra Help.......................................................................................................................................5

Are there any rules or limits on my drug coverage?................................................................................ 6

What if my drug is not on this list?.............................................................................................................8

How can I get an exception?......................................................................................................................8

Can I get my drug while I wait for an exception?......................................................................................9

Can the drug list change?........................................................................................................................ 10

Drugs with dosages other than a 1-month supply..................................................................................11

Covered drugs by name (Drug index)....................................................................................................12

Covered drugs by medical condition...................................................................................................... 29

Covered drugs with a quantity limit (QL).............................................................................................. 102

Additional covered drugs.......................................................................................................................133

Questions?

If you have questions, we’re here to help. Call Customer Service at:

Toll-free 1-800-407-9069, TTY 711

8 a.m. - 8 p.m. local time, 7 days a week

What is a drug list?

A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team

of health care providers work together in selecting drugs that are needed for well-rounded care and

treatment.

Your plan will generally cover the drugs listed in our drug list as long as:

· The drug is used for a medically accepted indication,

· The prescription is filled at a network pharmacy and

· Other plan rules are followed.

For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members:

This complete list of prescription drugs covered by your plan is current as of September 1, 2020.

For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our

contact information is on the cover.

This drug list has changed since last year. Please review this document to make sure your

prescription drugs are still covered. In most cases, you must use network pharmacies to have your

prescriptions covered by the plan.

When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to

“plan,” “our plan,” or “your plan,” it means Medica HealthCare Plans MedicareMax Plus.

3

How do I use the drug list?

There are 2 ways to find your prescription drugs in this drug list:

1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–28 to see the

.......list of drug names in alphabetical order. Find the name of your drug. The page number where

.......you can find the drug will be next to it.

2. By medical condition. Turn to section “Covered drugs by medical condition” on pages

.......29–101 to look for drugs based on your medical conditions. For example, if you have a heart

.......condition, you should look in the category Cardiovascular Agents. This is where you will find

.......drugs that treat heart conditions.

Can’t find your drug?Check the complete drug list by visiting our plan website at

www.Medicaplans.com. You can use online tools to look up your drugs. This

information is updated on a regular basis.

What are generic drugs?

Generic drugs have the same active ingredients as brand name drugs. They usually cost less than

brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers

both brand name and generic drugs.

Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then

review the drug list to make sure you are getting the drug you need for the least amount of money.

The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in

plain type (for example, Simvastatin).

What is a compounded drug?

A compounded drug is created by a pharmacist by combining or mixing ingredients to create a

prescription medication customized to the needs of an individual patient. Compounded drugs may

be Part D eligible. For more information about compounded drugs, please review your Evidence of

Coverage.

4

Drug payment stage and drug tiers

The amount you pay for a covered prescription drug will depend on:

· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a

prescription, the amount you pay depends on the coverage stage you’re in.

· Your drug’s tier. Each covered drug is in 1 of 5 drug tiers. Each tier has a copay or coinsurance

amount. The chart below shows the differences between the tiers.

If you need help or have any questions about your drug costs, please review your Evidence of

Coverage or call Customer Service. Our contact information is on the cover.

Drug Tier Includes

Tier 1: Lower-cost, commonly used generic drugs.

Preferred generic

Tier 2: Many generic drugs.

Generic

Tier 3: Many common brand name drugs, called preferred

Preferred brand brands and some higher-cost generic drugs.

Tier 4: Non-preferred generic and non-preferred brand name

Non-preferred drug drugs.

Tier 5: Unique and/or very high-cost brand and generic drugs.

Specialty tier

In addition, your plan has added coverage of some prescription drugs that are not normally covered

under Medicare Part D. Please see section “Additional covered drugs” on page 133 for a list of

these drugs.

Getting Extra Help

If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may

be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for

People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about

your costs. You can also call Customer Service. Our contact information is on the cover.

5

Are there any rules or limits on my drug coverage?Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug

has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use”

column of the “Covered drugs by medical condition” chart starting on page 29. The codes and

what they mean are shown below and on the next page.

You can also get more information about the coverage rules and/or limits applied to specific

covered drugs by visiting our website. We have posted online documents that explain our prior

authorization and step therapy restrictions. If you would like a copy sent to you, please call

Customer Service. Our contact information is on the cover.

Coverage Rules and Limits

PA - Prior authorization

The plan requires you or your doctor to get prior approval for certain drugs. This means the plan

needs more information from your doctor to make sure the drug is being used correctly for a

medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug.

QL - Quantity limits

The plan will cover only a certain amount of this drug for 1 copay or over a certain number of

days. These limits may be in place to ensure safe and effective use of the drug. If your doctor

prescribes more than this amount or thinks the limit is not right for your situation, you or your

doctor can ask the plan to cover the additional quantity.

ST - Step therapy

There may be effective, lower-cost drugs that treat the same medical condition as this drug. You

may be required to try 1 or more of these other drugs before the plan will cover your drug. If you

have already tried other drugs or your doctor thinks they are not right for you, you or your doctor

can ask the plan to cover this drug.

6

Other Special Coverage Rules

B/D - Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and

outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide

the plan with more information about how this drug will be used to make sure it’s correctly

covered by Medicare.

LA - Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain

facilities or doctors. These drugs may require extra handling, provider coordination or patient

education that can’t be done at a network pharmacy.

MME - Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of

pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is

designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1

opioid drug for pain management. If your doctor prescribes more than this amount or thinks the

limit is not right for your situation, you or your doctor can ask the plan to cover the additional

quantity.

7D - 7-Day limit

An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members

with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For

members who are new to the plan and have a recent history of using opioids, the limit may be

overridden by having the pharmacy contact the plan.

DL - Dispensing limit

Dispensing limits apply to this drug. This drug is limited to a 1-month supply per prescription.

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your

drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to

learn more.

If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules

or limits, you may have to pay the full cost of the drug.

7

What if my drug is not on this list?

If your drug is not included in this drug list we may still cover it. Call Customer Service to ask if it’s

covered. Our contact information, along with the date we last updated the drug list is on the cover.

If you find out that your drug is not covered, you can do 1 of these things:

1. Ask Customer Service for a list of similar drugs that are covered by the plan. When you get

the list, show it to your doctor and ask him or her to prescribe a covered drug.

2. Ask the plan to make an exception and cover your drug. Review the next section for more

exception information.

How can I get an exception?

Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This

is called asking for an exception. When you do, the plan will review your request and give you a

coverage decision known as a coverage determination.

Types of exceptions you can ask for

· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved,

this drug will be covered at a pre-determined cost sharing level. You will not be able to ask us to

provide the drug at a lower cost sharing level.

· Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For

example, if your drug has a quantity limit, you can ask the plan to change the limit and cover

more.

· Tiering exception: Ask the plan to cover your drug on our list at a lower cost sharing level if this

drug is not on the specialty tier. If approved this would lower the amount you pay out-of-pocket

for your drug.

The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as

effective in treating your condition or would cause adverse medical effects.

Who can ask for an exception?

You, your authorized representative or your doctor can ask for an exception by calling Customer

Service. Your doctor must give us a supporting statement with the reason for the exception.

How long does it take to get an exception?

After we get the statement from your doctor supporting your request for an exception, we’ll give

you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor

believes that your health could be seriously harmed by waiting 72 hours. If your request for an

expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s

supporting statement.

8

Can I get my drug while I wait for an exception?

As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s

not on our drug list or if it has rules or limits. For example, you may need a prior authorization from

us before you can fill your prescription. During the time when you are getting a temporary supply,

you should talk with your doctor to decide if there is a similar drug on the drug list you can take

instead. If you and your doctor decide this is the only drug that will work for you, you will need to

ask for an exception. We may cover your drug in certain cases during the first 90 days of your

membership.

The following chart shows how much of your drug we may cover while you ask for an exception.

The prescription must be filled at a network pharmacy. If your prescription is written for fewer days,

we’ll allow refills to provide at least the day supply listed in the chart above. (Please note that the

long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

We will not pay for more of your drug after you get this temporary or emergency supply unless you

receive authorization from the plan.

If you... And you are… We may cover…

are a new member in the first 90 days of

your membership

OR

were a member last year and it’s the

first 90 days of your plan year

not in a nursing home or

long-term care facility

in a nursing home or long-

term care facility

at least a 30-day

temporary supply

at least a 31-day

temporary supply

have been in the plan for more than 90

days


term care facility and

need a supply right away

at least a 31-day

emergency supply

are going through a change in your level

of care, such as being transferred from

a hospital to a long-term care facility,

any time during the year

not in a nursing home or

long-term care facility


term care facility

at least a 30-day

temporary supply

at least a 31-day

temporary supply

9

Can the drug list change?

Most changes in drug coverage happen on January 1. We may need to make changes during the

plan year for safety or other reasons that can affect you. We must follow the Medicare rules in

making these changes.

The drug list may change during the year if your plan:

· Adds new drugs, including generic drugs, as they become available.

· Removes a drug that has been found to be ineffective or unsafe.

· Changes the coverage rules or limits for a drug.

· Moves a drug into a different cost sharing tier.

If we add new generic drugs

We may immediately remove a brand name drug on our Drug List if we are replacing it with a new

generic drug that will appear on the same or lower cost sharing tier and with the same or fewer

restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug

on our Drug List, but immediately move it to a different cost sharing tier or add new restrictions. If

you are currently taking that brand name drug, we may not tell you in advance before we make that

change, but we will later provide you with information about the specific change(s) we have made.

If we make other changes

We may make other changes that affect members currently taking a drug. For instance, we may

add a generic drug that is not new to market to replace a brand name drug currently on the Drug

List; or add new restrictions to the brand name drug or move it to a different cost sharing tier or

both. Or we may make changes based on new clinical guidelines. If we remove drugs from our

Drug List, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move

a drug to a higher cost sharing tier, we must notify affected members of the change at least 30

days before the change becomes effective, or at the time the member requests a refill of the drug,

at which time the member will receive at least a 30 day supply of the drug.

If we add new generic drugs or make other changes, you or your prescriber can ask us to make

an exception and continue to cover the brand name drug for you. The notice we provide you will

also include information on how to request an exception, and you can also find information in the

section “How can I get an exception?” on page 8.

If we remove a drug from the list

If the Food and Drug Administration (FDA) says a drug you are taking is not effective or is unsafe,

we will let you know and take it off the drug list right away.

Changes that will not affect you if you are currently taking the drug

Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we

will not remove or reduce coverage during the year except as described above. You will not get a

notice this year about changes that do not affect you. However, on January 1 of the next year these

changes will affect you, therefore it is important to check the Drug List for any changes to drugs for

the new plan year.

10

Drugs with dosages other than a 1-month supply

Drugs packaged in an extended day supply

Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When

you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription.

For more information, please call Customer Service. Our contact information is on the cover.

Daily cost sharing for oral medications filled for less than a 1-month supply

A daily cost sharing rate may apply when your doctor prescribes less than a full month’s supply of

certain drugs for you and you are required to pay a copayment. A daily cost sharing rate is the

copayment divided by the number of days in a month’s supply.

Daily cost sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)

when dispensed for a supply of less than 1-month under applicable law. The daily cost sharing

requirements do not apply to either of the following:

1. Solid oral doses of antibiotics.

2. Solid oral doses that are dispensed in their original container or are usually dispensed in their

original packaging to help patients comply with usage and dosage directions.

For more information

For more detailed information about your plan’s prescription drug coverage, please review your

Evidence of Coverage and other plan materials.

If you have questions about your plan’s prescription drug coverage, please call Customer Service.

Our contact information, along with the date we last updated the drug list, is on the cover.

If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov

or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.

11

Covered drugs by name (Drug index)

A

Abacavir Sulfate..................... 56

Abacavir Sulfate-Lamivudine

.............................................. 56

Abacavir-Lamivudine-

Zidovudine........................... 56

Abelcet....................................43

Abilify Maintena......................52

Abiraterone Acetate...............46

Acamprosate Calcium........... 32

Acarbose................................ 59

Acebutolol HCl....................... 64

Acetaminophen-Codeine...... 30

Acetazolamide........................66

Acetazolamide ER..................66

Acetic Acid............................. 97

Acetylcysteine........................ 99

Acitretin...................................71

Actemra.................................. 89

Actemra ACTPen................... 89

ActHIB.....................................91

Actimmune............................. 89

Acyclovir................................. 55

Acyclovir Sodium................... 55

Adacel.....................................91

Adapalene.............................. 71

Adefovir Dipivoxil................... 54

Adempas................................ 99

Advair Diskus......................... 99

Advair HFA..............................99

Afinitor.....................................47

Afinitor Disperz.......................47

Aimovig................................... 45

Ala-Cort................................... 72

Albendazole............................50

Albuterol Sulfate.................... 98

Albuterol Sulfate HFA............ 98

Alclometasone Dipropionate

.............................................. 72

Alcohol Prep Pads................. 93

Alecensa................................. 47

Alendronate Sodium..............93

Alfuzosin HCl ER....................80

Alinia....................................... 50

Aliskiren Fumarate................. 66

Allopurinol.............................. 44

Alocril...................................... 94

Alomide...................................94

Alosetron HCl......................... 78

Alphagan P............................. 96

Alprazolam..............................58

Altavera................................... 82

Alunbrig.................................. 47

Alyacen 1/35.......................... 82

Alyq......................................... 99

Amantadine HCl.....................51

AmBisome.............................. 43

Ambrisentan........................... 99

Amethia...................................82

Amikacin Sulfate.................... 32

Amiloride HCl......................... 67

Amiloride-Hydrochlorothiazide

.............................................. 66

Aminosyn II............................. 75

Aminosyn-PF.......................... 75

Amiodarone HCl.....................64

Amitiza.................................... 78

Amitriptyline HCl.................... 42

Amlodipine Besylate..............65

Amlodipine-Atorvastatin........ 66

Amlodipine-Benazepril.......... 66

Amlodipine-Olmesartan.........66

Amlodipine-Valsartan.............66

Amlodipine-Valsartan-HCTZ

.............................................. 66

Ammonium Lactate............... 72

Amnesteem............................ 71

Amoxapine............................. 42

Amoxicillin.............................. 35

Amoxicillin-Potassium

Clavulanate.......................... 35

Amoxicillin-Potassium

Clavulanate ER.................... 35

Amphetamine-

Dextroamphetamine............69

Amphetamine-

Dextroamphetamine ER......69

Amphotericin B...................... 43

Ampicillin................................ 35

Ampicillin Sodium..................35

Ampicillin-Sulbactam Sodium

.............................................. 35

Anadrol-50.............................. 82

Anagrelide HCl.......................62

Anastrozole.............................47

Androderm............................. 82

Anoro Ellipta...........................99

Apokyn....................................51

Apraclonidine HCl..................96

Aprepitant...............................43

Apri..........................................82

Apriso......................................92

Aptiom.................................... 39

12

Aptivus.....................................57

Aralast NP............................... 79

Aranelle................................... 82

Aranesp................................... 62

Arcalyst....................................89

Aripiprazole.............................52

Aripiprazole ODT.................... 52

Aristada................................... 52

Aristada Initio.......................... 52

Armodafinil............................100

Arnuity Ellipta..........................97

Ashlyna....................................82

Aspirin-Dipyridamole ER........63

Atazanavir Sulfate...................57

Atenolol................................... 64

Atenolol-Chlorthalidone......... 66

Atomoxetine HCl.................... 70

Atorvastatin Calcium.............. 68

Atovaquone.............................50

Atovaquone-Proguanil HCl.... 50

Atripla...................................... 55

Atropine Sulfate......................94

Atrovent HFA...........................98

Aubagio................................... 70

Aubra EQ.................................82

Auryxia.....................................77

Austedo................................... 70

Aviane......................................82

Avonex Pen............................. 70

Avonex Prefilled......................70

Ayvakit..................................... 47

Azathioprine............................90

Azelaic Acid............................ 71

Azelastine HCl.................. 94, 97

Azelastine-Fluticasone........... 97

Azithromycin........................... 36

Azopt....................................... 96

Aztreonam...............................33

B

Bacitracin................................ 95

Bacitracin-Polymyxin B.......... 95

Baclofen.................................. 54

Balsalazide Disodium.............92

Balversa...................................47

Balziva..................................... 82

Banzel......................................39

Baqsimi Two Pack..................60

Baraclude................................54

BCG Vaccine...........................91

Belsomra...............................100

Benazepril HCl........................64

Benazepril-Hydrochlorothiazide

...............................................66

Benlysta...................................89

Benznidazole.......................... 50

Benzoyl Peroxide-Erythromycin

...............................................71

Benztropine Mesylate............ 51

Bepreve................................... 94

Berinert....................................88

Besivance................................95

Betamethasone Dipropionate

...............................................72

Betamethasone Dipropionate

Aug........................................ 72

Betamethasone Valerate........72

Betaseron................................71

Betaxolol HCl....................64, 96

Bethanechol Chloride............ 81

Bethkis.....................................98

Betimol.................................... 96

Bevespi Aerosphere...............99

Bexarotene..............................50

Bexsero................................... 91

Bicalutamide........................... 46

Bicillin C-R...............................35

Bicillin C-R 900/300............... 35

Bicillin L-A............................... 35

BiDil......................................... 66

Biktarvy....................................55

Bisoprolol Fumarate...............64

Bisoprolol-Hydrochlorothiazide

...............................................66

BIVIGAM..................................88

Blephamide.............................94

Blephamide S.O.P.................. 94

Blisovi 24 Fe............................83

Blisovi Fe 1.5/30.....................83

Boostrix................................... 91

Bosentan................................. 99

Bosulif......................................47

Braftovi.................................... 47

Breo Ellipta............................100

Briellyn.....................................83

Brilinta..................................... 63

Brimonidine Tartrate.............. 96

BRIVIACT................................ 38

Bromocriptine Mesylate.........51

Brukinsa.................................. 47

Budesonide...................... 93, 97

Budesonide ER.......................93

Bumetanide.............................67

Buprenorphine........................30

13

Buprenorphine HCl................ 32

Buprenorphine HCl-Naloxone

HCl.........................................32

Bupropion HCl........................ 41

Bupropion HCl SR............32, 41

Bupropion HCl XL.................. 41

Buspirone HCl........................ 58

Butalbital-Acetaminophen-

Caffeine.................................30

Butalbital-Aspirin-Caffeine..... 30

Butorphanol Tartrate..............30

Bydureon.................................59

Bydureon BCise......................59

Byetta 10MCG Pen.................59

Byetta 5MCG Pen...................59

Bystolic....................................64

C

Cabergoline............................ 87

Cablivi......................................63

Cabometyx..............................47

Calcipotriene...........................73

Calcitonin Salmon.................. 93

Calcitriol............................ 73, 93

Calcium Acetate..................... 77

Calquence...............................47

Camila..................................... 86

Camrese Lo.............................83

Candesartan Cilexetil............. 63

Candesartan Cilexetil-HCTZ

...............................................66

Caplyta.................................... 52

Caprelsa.................................. 47

Captopril..................................64

Captopril-Hydrochlorothiazide

...............................................66

Carbaglu..................................75

Carbamazepine...................... 40

Carbamazepine ER.......... 39, 40

Carbidopa............................... 51

Carbidopa-Levodopa............. 51

Carbidopa-Levodopa ER....... 51

Carbidopa-Levodopa ODT.....51

Carbidopa-Levodopa-

Entacapone.......................... 51

Carteolol HCl...........................96

Cartia XT..................................65

Carvedilol................................ 64

Cayston................................... 98

Caziant.....................................83

Cefaclor...................................34

Cefadroxil................................34

Cefazolin Sodium................... 34

Cefdinir....................................34

Cefepime HCl......................... 34

Cefixime.................................. 34

Cefotetan Disodium............... 34

Cefoxitin Sodium.................... 34

Cefpodoxime Proxetil.............34

Cefprozil.................................. 34

Ceftazidime............................. 34

Ceftriaxone Sodium................34

Cefuroxime Axetil................... 34

Cefuroxime Sodium............... 35

Celecoxib................................ 29

Celontin................................... 39

Cephalexin.............................. 35

Cetirizine HCl.......................... 97

Chantix.................................... 32

Chantix Continuing Month Pak

...............................................32

Chantix Starting Month Pak...32

Chemet....................................77

Chenodal.................................78

Chlordiazepoxide HCl............ 58

Chlorhexidine Gluconate....... 71

Chloroquine Phosphate......... 50

Chlorpromazine HCl...............52

Chlorthalidone........................ 67

Chlorzoxazone......................100

Cholbam..................................79

Cholestyramine.......................68

Cholestyramine Light............. 68

Ciclopirox................................ 74

Ciclopirox Olamine.................74

Cilostazol.................................63

Ciloxan.....................................95

Cimduo....................................56

Cimetidine...............................79

Cimetidine HCl........................79

Cimzia......................................90

Cimzia Prefilled.......................90

Cinacalcet HCl........................ 93

Cinryze.....................................88

Cipro HC..................................97

Ciprofloxacin HCl............. 37, 95

Ciprofloxacin in D5W............. 37

Citalopram Hydrobromide.....41

Claravis....................................71

Clarithromycin.........................36

Clarithromycin ER...................36

Clenpiq.................................... 78

Climara Pro............................. 83

Clindacin-P..............................74

Clindamycin HCl.....................33

14

Clindamycin Palmitate HCl.... 33

Clindamycin Phosphate...33, 74

Clindamycin Phosphate in D5W

...............................................33

Clindamycin Phosphate-

Benzoyl Peroxide................. 71

Clobazam................................ 39

Clobetasol Propionate........... 72

Clobetasol Propionate

Emollient Base......................72

Clomipramine HCl.................. 42

Clonazepam............................58

Clonazepam ODT................... 58

Clonidine................................. 63

Clonidine HCl..........................63

Clonidine HCl ER....................70

Clopidogrel Bisulfate..............63

Clorazepate Dipotassium.......58

Clotrimazole......................43, 74

Clotrimazole-Betamethasone

...............................................73

Clovique.................................. 77

Clozapine................................ 54

Clozapine ODT....................... 54

Coartem...................................50

Codeine Sulfate...................... 30

Colchicine............................... 44

Colesevelam HCl.................... 68

Colestipol HCl.........................68

Colistimethate Sodium...........33

Combigan................................94

Combivent Respimat........... 100

Cometriq................................. 47

Complera.................................55

Compro................................... 42

Constulose.............................. 78

Copiktra...................................47

Cordran................................... 72

Corlanor...................................66

Cortisone Acetate...................81

Cortisporin........................ 73, 74

Cosentyx................................. 89

Cosentyx Sensoready............ 89

Cotellic.....................................47

Creon.......................................79

Crinone....................................86

Crixivan....................................57

Cromolyn Sodium...... 79, 94, 99

Cryselle-28.............................. 83

Cuvposa.................................. 78

Cyclafem 1/35........................ 83

Cyclafem 7/7/7.......................83

Cyclobenzaprine HCl........... 100

Cyclophosphamide................ 45

Cycloset...................................59

Cyclosporine...........................90

Cyclosporine Modified...........90

Cyproheptadine HCl...............97

Cyred EQ.................................83

Cystadane............................... 79

Cystagon................................. 79

Cystaran.................................. 94

D

Dalfampridine ER................... 71

Daliresp................................... 99

Dalvance..................................33

Danazol....................................82

Dantrolene Sodium................ 54

Dapsone.................................. 45

Daptacel.................................. 91

Daptomycin.............................33

DARAPRIM............................. 50

Daurismo.................................47

Deblitane................................. 86

Deferasirox..............................77

Delstrigo.................................. 55

Demeclocycline HCl...............37

Demser....................................66

Depen Titratabs...................... 81

Depo-Estradiol........................ 83

Depo-Provera.......................... 86

Descovy...................................56

Desipramine HCl.................... 42

Desmopressin Acetate...........81

Desmopressin Acetate Spray

...............................................81

Desogestrel-Ethinyl Estradiol

...............................................83

Desonide................................. 72

Desoximetasone.....................72

Desvenlafaxine Succinate ER

...............................................41

Dexamethasone......................81

Dexamethasone Intensol....... 81

Dexamethasone Sodium

Phosphate.............................95

Dexilant....................................79

Dexmethylphenidate HCl.......70

Dexmethylphenidate HCl ER

...............................................70

Dextroamphetamine Sulfate

...............................................69

Dextroamphetamine Sulfate ER

...............................................69

Dextrose.................................. 75

15

Dextrose-NaCl.........................75

Diazepam.......................... 39, 58

Diazepam Intensol..................58

Diazoxide.................................60

Diclofenac Epolamine............ 29

Diclofenac Potassium............ 29

Diclofenac Sodium.... 29, 74, 95

Diclofenac Sodium ER........... 29

Dicloxacillin Sodium...............35

Dicyclomine HCl..................... 78

Didanosine.............................. 56

Dificid.......................................36

Diflunisal..................................29

Digitek..................................... 66

Digox....................................... 66

Digoxin.................................... 66

Dihydroergotamine Mesylate

...............................................44

Dilantin.................................... 40

Dilantin INFATABS................. 40

Dilt-XR......................................65

Diltiazem HCl.......................... 65

Diltiazem HCl ER.................... 65

Diltiazem HCl ER Beads........ 65

Diltiazem HCl ER Coated

Beads.................................... 65

Dipentum.................................92

Diphenoxylate-Atropine..........78

Diphtheria-Tetanus Toxoids DT

...............................................91

Disulfiram................................ 32

Diuril.........................................68

Divalproex Sodium................. 58

Divalproex Sodium ER........... 58

Dofetilide................................. 64

Donepezil HCl.........................40

Donepezil HCl ODT................ 40

Dorzolamide HCl.................... 96

Dorzolamide HCl-Timolol

Maleate................................. 94

Dorzolamide HCl-Timolol

Maleate Preservative Free... 94

Dovato..................................... 55

Doxazosin Mesylate............... 63

Doxepin HCl......................42, 72

Doxercalciferol........................93

Doxy 100................................. 37

Doxycycline Hyclate............... 37

Doxycycline Monohydrate..... 37

Drizalma Sprinkle................... 70

Dronabinol...............................43

Drospirenone-Ethinyl Estradiol

...............................................83

Droxia...................................... 46

Duavee.................................... 83

Dulera....................................100

Duloxetine HCl........................70

Duramorph..............................30

Dutasteride..............................80

Dymista....................................97

E

E.E.S. Granules.......................36

Econazole Nitrate................... 74

Edarbi...................................... 63

Edarbyclor...............................67

Edurant....................................56

Efavirenz..................................56

Egrifta...................................... 81

Egrifta SV................................ 81

Elestrin.....................................83

Eliquis...................................... 61

Eliquis Starter Pack................ 61

Elmiron.................................... 81

EluRyng................................... 83

Emcyt.......................................46

Emgality...................................45

Emoquette...............................83

Emsam.....................................41

Emtriva.....................................56

Enalapril Maleate.................... 64

Enalapril-Hydrochlorothiazide

...............................................67

Enbrel...................................... 90

Enbrel Mini.............................. 90

Enbrel SureClick.....................90

Endocet................................... 30

Engerix-B.................................91

Enoxaparin Sodium................61

Enpresse-28............................ 83

Enskyce................................... 83

Entacapone.............................51

Entecavir..................................55

Entresto................................... 67

Enulose....................................78

Envarsus XR............................90

Epclusa....................................55

Epidiolex..................................38

Epinastine HCl........................ 94

Epinephrine.............................98

Epitol........................................40

Epivir HBV............................... 55

Eplerenone..............................67

Ergotamine-Caffeine...............44

Erivedge.................................. 47

16

Erleada.................................... 46

Erlotinib HCl............................47

Errin......................................... 86

Ertapenem Sodium................ 36

Ery............................................74

Erythrocin Lactobionate.........36

Erythromycin.....................74, 95

Erythromycin Base................. 36

Erythromycin Ethylsuccinate

.........................................36, 37

Esbriet..................................... 99

Escitalopram Oxalate............. 41

Esomeprazole Magnesium.... 79

Estarylla................................... 83

Estradiol.................................. 83

Estradiol Valerate....................83

Estring..................................... 83

Ethacrynic Acid.......................67

Ethambutol HCl...................... 45

Ethosuximide.......................... 39

Ethynodiol Diacetate-Ethinyl

Estradiol................................ 83

Etodolac.................................. 29

Etodolac ER............................ 29

Etonogestrel-Ethinyl Estradiol

...............................................83

Euthyrox.................................. 87

Everolimus........................ 48, 90

Evotaz...................................... 57

Exemestane............................ 47

Ezetimibe.................................68

Ezetimibe-Simvastatin............ 68

F

Falmina....................................83

Famciclovir..............................55

Famotidine.............................. 79

Fanapt............................... 52, 53

Fanapt Titration Pack............. 53

Farxiga.....................................59

Farydak....................................48

Fasenra..................................100

Fasenra Pen..........................100

Fayosim................................... 83

Febuxostat.............................. 44

Felbamate............................... 38

Felodipine ER......................... 65

Femring................................... 83

Femynor.................................. 83

Fenofibrate..............................68

Fenofibrate Micronized.......... 68

Fenofibric Acid....................... 68

Fentanyl...................................30

Fentanyl Citrate.......................31

Ferriprox..................................77

Fetzima....................................41

Fetzima Titration..................... 41

Finacea....................................71

Finasteride.............................. 80

Firmagon................................. 87

Flac.......................................... 97

Flarex....................................... 95

Flebogamma DIF.................... 88

Flecainide Acetate..................64

Flovent Diskus........................ 97

Flovent HFA.............................97

Fluconazole.............................43

Fluconazole in Sodium

Chloride................................ 43

Flucytosine..............................43

Fludrocortisone Acetate........ 81

Flunisolide...............................97

Fluocinolone Acetonide...72, 97

Fluocinolone Acetonide Scalp

...............................................72

Fluocinonide........................... 73

Fluocinonide Emulsified Base

...............................................73

Fluorometholone.................... 95

Fluorouracil............................. 74

Fluoxetine HCl........................ 41

Fluphenazine Decanoate....... 52

Fluphenazine HCl................... 52

Flurbiprofen.............................29

Flurbiprofen Sodium.............. 95

Flutamide................................ 46

Fluticasone Propionate....73, 97

Fluticasone-Salmeterol........ 100

Fluvastatin Sodium.................68

Fluvoxamine Maleate............. 41

FML..........................................95

FML Forte................................95

Fondaparinux Sodium..... 61, 62

Forteo...................................... 93

Fosamprenavir Calcium......... 57

Fosinopril Sodium.................. 64

Fosinopril Sodium-HCTZ....... 67

FreAmine HBC........................75

Furosemide............................. 67

Fuzeon.....................................57

Fyavolv.....................................83

Fycompa..................................38

G

Gabapentin............................. 39

17

Galantamine Hydrobromide

...............................................40

Galantamine Hydrobromide ER

...............................................40

Gammagard............................ 88

Gammagard S/D Less IgA.....88

Gammaked............................. 88

Gammaplex.............................89

Gamunex-C............................. 89

Gardasil 9................................ 91

Gatifloxacin............................. 95

Gattex...................................... 78

Gauze...................................... 93

GaviLyte-C...............................78

GaviLyte-G...............................78

GaviLyte-N with Flavor Pack

...............................................78

Gemfibrozil..............................68

Generlac..................................78

Gengraf................................... 90

Genotropin.............................. 82

Genotropin MiniQuick............82

Gentak..................................... 95

Gentamicin Sulfate.... 32, 75, 95

Gentamicin Sulfate-0.9%

Sodium Chloride.................. 32

Genvoya.................................. 55

Geodon....................................53

Gianvi.......................................83

Gilenya.....................................71

Gilotrif...................................... 48

Glassia.....................................79

Glatiramer Acetate................. 71

Glatopa....................................71

Glimepiride..............................59

Glipizide...................................59

Glipizide ER............................ 59

Glipizide-Metformin HCl.........59

GlucaGen HypoKit..................60

Glucagon.................................60

Glyxambi................................. 59

Granisetron HCl...................... 43

Granix...................................... 62

Griseofulvin Microsize............43

Griseofulvin Ultramicrosize....43

Guanfacine HCl ER................ 70

Guanidine HCl........................ 45

Gvoke HypoPen 2-Pack......... 60

Gvoke PFS.............................. 60

H

Haegarda.................................88

Hailey 24 Fe............................ 83

Halobetasol Propionate......... 73

Haloperidol..............................52

Haloperidol Decanoate.......... 52

Haloperidol Lactate................52

Havrix.......................................91

Heparin Sodium......................62

HepatAmine............................ 75

Hetlioz....................................100

Hiberix..................................... 91

Humalog..................................60

Humalog Junior KwikPen...... 60

Humalog KwikPen.................. 60

Humalog Mix 50/50................60

Humalog Mix 50/50 KwikPen

...............................................60

Humalog Mix 75/25................60

Humalog Mix 75/25 KwikPen

...............................................60

Humira.....................................90

Humira Pediatric Crohns Start

...............................................90

Humira Pen............................. 90

Humira Pen Crohns Disease

Starter....................................90

Humira Pen Psoriasis Starter

...............................................90

Humulin 70/30........................61

Humulin 70/30 KwikPen........ 61

Humulin N............................... 61

Humulin N KwikPen............... 61

Humulin R............................... 61

Humulin R U-500.................... 61

Humulin R U-500 KwikPen.....61

Hydralazine HCl...................... 69

Hydrochlorothiazide............... 68

Hydrocodone-Acetaminophen

...............................................31

Hydrocodone-Ibuprofen.........31

Hydrocortisone...........73, 81, 93

Hydrocortisone Butyrate........73

Hydrocortisone Valerate........ 73

Hydrocortisone-Acetic Acid...97

Hydromorphone HCl.............. 31

Hydromorphone HCl ER........ 30

Hydromorphone HCl

Preservative Free..................31

Hydroxychloroquine Sulfate

...............................................50

Hydroxyurea............................46

Hydroxyzine HCl..................... 58

Hydroxyzine Pamoate............ 58

I

Ibandronate Sodium...............93

Ibrance.................................... 48

18

Ibu............................................29

Ibuprofen.................................29

Icatibant Acetate.....................88

Iclusig...................................... 48

IDHIFA..................................... 46

Ilevro........................................ 95

Imatinib Mesylate....................48

Imbruvica.................................48

Imipenem-Cilastatin................36

Imipramine HCl.......................42

Imipramine Pamoate.............. 42

Imiquimod............................... 74

Imiquimod Pump.................... 74

Imovax Rabies........................ 91

Imvexxy Maintenance Pack... 83

Imvexxy Starter Pack..............83

Incassia................................... 86

Increlex....................................82

Incruse Ellipta......................... 98

Indapamide............................. 68

Indomethacin.......................... 29

Infanrix.....................................91

Ingrezza................................... 70

Inlyta........................................ 48

Inrebic......................................48

Insulin Lispro...........................61

Insulin Lispro Junior KwikPen

...............................................61

Insulin Lispro Prot & Lispro... 61

Insulin Syringes, Needles...... 93

Intelence..................................56

Intralipid...................................75

Intron A....................................89

Introvale...................................84

Invega Sustenna..................... 53

Invega Trinza...........................53

Invirase.................................... 57

IPOL.........................................91

Ipratropium Bromide..............98

Ipratropium-Albuterol........... 100

Irbesartan................................ 63

Irbesartan-Hydrochlorothiazide

...............................................67

Iressa....................................... 48

Isentress.................................. 55

Isentress HD............................55

Isibloom...................................84

Isolyte-P in D5W......................75

Isolyte-S................................... 75

Isoniazid.................................. 45

Isosorbide Dinitrate................ 69

Isosorbide Mononitrate..........69

Isosorbide Mononitrate ER....69

Isotretinoin.............................. 71

Itraconazole.............................43

Ivermectin................................50

Ixiaro........................................ 91

J

Jadenu Sprinkle......................77

Jakafi....................................... 48

Jantoven..................................62

Janumet...................................59

Janumet XR.............................59

Januvia.................................... 59

Jardiance.................................59

Jasmiel.................................... 84

Jentadueto.............................. 59

Jentadueto XR........................ 59

Jinteli....................................... 84

Jublia....................................... 75

Juleber.....................................84

Juluca...................................... 55

Junel 1.5/30............................84

Junel 1/20............................... 84

Junel Fe 1.5/30.......................84

Junel Fe 1/20..........................84

Junel Fe 24..............................84

Juxtapid...................................68

K

Kaitlib Fe..................................84

Kaletra..................................... 57

Kalydeco..................................98

Kariva.......................................84

KCl in Dextrose-NaCl..............75

KCl-Lactated Ringers-D5W.... 75

Kelnor 1/35............................. 84

Kelnor 1/50............................. 84

Ketoconazole....................43, 75

Ketoprofen.............................. 29

Ketorolac Tromethamine....... 95

Kineret..................................... 89

Kinrix........................................91

Kionex......................................77

Kisqali...................................... 48

Kisqali Femara........................ 48

Klor-Con.................................. 76

Klor-Con 10............................. 75

Klor-Con 8............................... 76

Klor-Con M10..........................76

Klor-Con M15..........................76

Klor-Con M20..........................76

Korlym..................................... 82

19

Koselugo................................. 48

Kurvelo.................................... 84

Kuvan.......................................80

L

Labetalol HCl.......................... 65

Lacrisert...................................94

Lactulose.................................78

Lamivudine....................... 55, 56

Lamivudine-Zidovudine..........56

Lamotrigine............................. 38

Lanoxin....................................67

Lansoprazole.......................... 79

Lanthanum Carbonate........... 77

Lantus......................................61

Lantus SoloStar...................... 61

LARIN 1.5/30.......................... 84

LARIN 1/20............................. 84

LARIN Fe 1.5/30.....................84

LARIN Fe 1/20........................84

Larissia.................................... 84

Lastacaft..................................94

Latanoprost.............................96

Latuda......................................53

Layolis Fe................................ 84

Leena.......................................84

Leflunomide............................ 90

Lenvima 10MG Daily Dose.... 48






Lenvima 4MG Daily Dose...... 49

Lenvima 8MG Daily Dose...... 49

Lessina.................................... 84

Letrozole..................................47

Leucovorin Calcium............... 50

Leukeran................................. 45

Leukine....................................62

Leuprolide Acetate................. 87

Levalbuterol HCl..................... 98

Levemir....................................61

Levemir FlexTouch.................61

Levetiracetam......................... 38

Levetiracetam ER................... 38

Levo-T......................................87

Levobunolol HCl..................... 96

Levocarnitine.......................... 80

Levocetirizine Dihydrochloride

...............................................97

Levofloxacin......................37, 95

Levofloxacin in D5W...............37

Levonest..................................84

Levonorgestrel-Ethinyl Estradiol

...............................................84


& Ethinyl Estradiol................ 84


91-Day................................... 84

Levora 0.15/30....................... 84

Levorphanol Tartrate..............30

Levothyroxine Sodium........... 87

Levoxyl.....................................87

Lexiva.......................................57

Lidocaine.................................31

Lidocaine HCl................... 31, 32

Lidocaine Viscous.................. 32

Lidocaine-Prilocaine...............32

Linezolid.................................. 33

Linzess.....................................78

Liothyronine Sodium..............87

Lisinopril..................................64

Lisinopril-Hydrochlorothiazide

...............................................67

Lithium.....................................59

Lithium Carbonate..................58

Lithium Carbonate ER............58

Lithostat...................................81

Livalo....................................... 68

Lokelma...................................77

Lonhala Magnair.....................98

Lonsurf.................................... 46

Loperamide HCl..................... 78

Lopinavir-Ritonavir..................57

Lorazepam.............................. 58

Lorazepam Intensol................58

Lorbrena..................................49

Lorcet...................................... 31

Lorcet HD................................31

Lorcet Plus.............................. 31

Loryna......................................84

Losartan Potassium................63

Losartan Potassium-HCTZ.....67

Lotemax...................................96

Lotemax SM............................96

Loteprednol Etabonate.......... 96

Lovastatin................................68

Low-Ogestrel...........................84

Loxapine Succinate................52

Lumigan.................................. 96

Lupaneta Pack........................87

Lupron Depot................... 87, 88

Lutera...................................... 84

20

Lynparza..................................49

Lysodren................................. 87

Lyza..........................................86

M

M-M-R II................................... 92

Magnesium Sulfate.................76

Malathion.................................74

Maprotiline HCl.......................41

Marlissa................................... 84

Marplan................................... 41

Matulane..................................46

Matzim LA............................... 65

Mavyret....................................55

Mayzent................................... 71

Meclizine HCl..........................42

Medroxyprogesterone Acetate

...............................................86

Mefloquine HCl.......................50

Megestrol Acetate.................. 87

Mekinist................................... 49

Mektovi....................................49

Melodetta 24 Fe......................84

Meloxicam...............................29

Memantine HCl.......................41

Memantine HCl ER.................40

Memantine HCl Titration Pak

...............................................41

Menactra................................. 91

Menest.....................................85

Mentax.....................................75

Menveo....................................91

Mercaptopurine...................... 46

Meropenem.............................36

Mesalamine.............................92

Mesalamine ER.......................92

Mesnex....................................50

Metaproterenol Sulfate.......... 98

Metformin HCl.........................59

Metformin HCl ER...................59

Methadone HCl.......................30

Methazolamide....................... 96

Methenamine Hippurate........ 33

Methimazole............................88

Methotrexate...........................90

Methotrexate Sodium.............90

Methoxsalen Rapid................ 74

Methscopolamine Bromide... 78

Methyldopa............................. 63

Methyldopa-

Hydrochlorothiazide.............67

Methylphenidate HCl..............70

Methylphenidate HCl ER........70

Methylprednisolone................81

Metoclopramide HCl.............. 42

Metolazone............................. 68

Metoprolol Succinate ER.......65

Metoprolol Tartrate.................65

Metoprolol-Hydrochlorothiazide

...............................................67

Metronidazole......................... 33

Metronidazole in NaCl 0.79%

...............................................33

Mexiletine HCl.........................64

Mibelas 24 Fe......................... 85

Micafungin Sodium................ 43

Miconazole 3...........................43

Microgestin 1.5/30................. 85

Microgestin 1/20.................... 85

Microgestin Fe 1.5/30............85

Microgestin Fe 1/20............... 85

Midodrine HCl.........................63

Migergot..................................45

Miglitol.....................................59

Miglustat..................................80

Mili........................................... 85

Minitran................................... 69

Minocycline HCl......................37

Minoxidil..................................69

Mirtazapine............................. 41

Mirtazapine ODT.....................41

Mirvaso....................................71

Misoprostol............................. 79

Modafinil............................... 100

Moexipril HCl.......................... 64

Molindone HCl........................52

Mometasone Furoate.......73, 97

Montelukast Sodium.............. 97

Morphine Sulfate.................... 31

Morphine Sulfate ER.............. 30

Moxifloxacin HCl.............. 37, 95

Moxifloxacin HCl in NaCl....... 37

Multaq......................................64

Mupirocin................................ 75

Mupirocin Calcium................. 75

Myalept....................................78

Mycophenolate Mofetil.... 90, 91

Mycophenolate Sodium.........91

Myorisan..................................71

Myrbetriq.................................80

N

Nabumetone........................... 29

Nadolol.................................... 65

Nafcillin Sodium............... 35, 36

Naftifine HCl............................75

21

Naftin....................................... 75

Naloxone HCl..........................32

Naltrexone HCl....................... 32

Namzaric................................. 40

Naproxen.................................29

Naproxen DR.......................... 29

Naratriptan HCl.......................44

Narcan..................................... 32

Natacyn................................... 95

Nateglinide..............................59

Natpara....................................93

Nayzilam..................................39

Necon 0.5/35..........................85

Nefazodone HCl..................... 41

Neomycin Sulfate................... 32

Neomycin-Bacitracin-Polymyxin

...............................................95

Neomycin-Polymyxin-

Bacitracin-Hydrocortisone...94

Neomycin-Polymyxin-

Dexamethasone................... 94

Neomycin-Polymyxin-

Gramicidin............................ 95

Neomycin-Polymyxin-HC.......94,

97

NephrAmine............................76

Nerlynx.................................... 49

Neulasta.................................. 62

Neupogen............................... 62

Neupro.....................................51

Nevirapine............................... 56

Nevirapine ER......................... 56

Nexavar................................... 49

Niacin ER.................................68

Niacor...................................... 68

Nicardipine HCl...................... 65

Nicotrol....................................32

Nicotrol NS..............................32

Nifedipine ER..........................65

Nifedipine ER Osmotic Release

...............................................65

Nikki.........................................85

Nilutamide............................... 46

Nimodipine..............................65

Ninlaro..................................... 46

Nitisinone................................ 80

Nitro-Bid.................................. 69

Nitrofurantoin..........................33

Nitrofurantoin Macrocrystal...33

Nitrofurantoin Monohydrate

...............................................33

Nitroglycerin............................69

Nitrostat...................................69

Nizatidine................................ 79

Nora-BE................................... 87

Norethindrone.........................87

Norethindrone Acetate...........87

Norethindrone Acetate-Ethinyl

Estradiol................................ 85

Norethindrone Acetate-Ethinyl

Estradiol-Fe...........................85

Norgestimate-Ethinyl Estradiol

...............................................85

Norgestimate-Ethinyl Estradiol

Triphasic............................... 85

Normosol-M in D5W............... 76

Normosol-R............................. 76

Northera.................................. 63

Nortrel 0.5/35......................... 85

Nortrel 1/35.............................85

Nortrel 7/7/7...........................85

Nortriptyline HCl..................... 42

Norvir....................................... 57

Noxafil......................................43

Nubeqa....................................46

Nucala................................... 100

Nucynta ER............................. 30

Nuedexta.................................70

Nuplazid.................................. 53

Nutrilipid..................................76

Nyamyc....................................75

Nymalize..................................65

Nystatin............................. 43, 75

Nystop..................................... 75

O

Ocaliva.....................................78

Ocella...................................... 85

Octagam..................................89

Octreotide Acetate................. 88

Odefsey................................... 56

Odomzo...................................49

Ofev......................................... 99

Ofloxacin.....................37, 95, 97

Olanzapine.............................. 53

Olanzapine ODT..................... 53

Olmesartan Medoxomil..........63

Olmesartan Medoxomil-HCTZ

...............................................67

Olmesartan-Amlodipine-HCTZ

...............................................67

Olopatadine HCl..................... 95

Omega-3-Acid Ethyl Esters.... 69

Omeprazole.............................79

Ondansetron HCl....................43

Ondansetron ODT.................. 43

Opsumit...................................99

22

Orencia....................................89

Orencia ClickJect................... 89

Orenitram................................ 99

Orfadin.....................................80

Orkambi...................................98

Orsythia................................... 85

Oseltamivir Phosphate........... 57

Osphena..................................87

Otezla...................................... 89

Oxacillin Sodium.....................36

Oxacillin Sodium in Dextrose

...............................................36

Oxandrolone........................... 82

Oxcarbazepine........................40

Oxybutynin Chloride...............80

Oxybutynin Chloride ER.........80

Oxycodone HCl...................... 31

Oxycodone-Acetaminophen

...............................................31

Oxycodone-Aspirin................. 31

Ozempic.................................. 59

P

Pacerone................................. 64

Paliperidone ER......................53

Pantoprazole Sodium.............79

Panzyga...................................89

Paricalcitol...............................93

Paromomycin Sulfate.............33

Paroxetine HCl........................41

Paser........................................45

Paxil......................................... 42

Pazeo.......................................95

Pediarix....................................92

Pedvax HIB..............................92

PEG-3350-Electrolytes............79

PEG-3350-NaCl-Na

Bicarbonate-KCl................... 78

Peganone................................40

Pegasys ProClick....................90

Pemazyre.................................46

Penicillamine...........................81

Penicillin G Potassium........... 36

Penicillin G Procaine.............. 36

Penicillin G Sodium................36

Penicillin V Potassium............36

Pentamidine Isethionate........ 51

Pentasa....................................92

Pentoxifylline ER.....................67

Perforomist..............................98

Perindopril Erbumine............. 64

Permethrin...............................74

Perphenazine..........................42

Perseris....................................53

Phenelzine Sulfate..................41

Phenobarbital......................... 39

Phenoxybenzamine HCl.........63

Phenytek................................. 40

Phenytoin................................ 40

Phenytoin Sodium Extended

...............................................40

Phoslyra...................................77

Phospholine Iodide................ 96

Picato.......................................74

Pifeltro..................................... 56

Pilocarpine HCl.................71, 96

Pimecrolimus.......................... 73

Pimozide..................................52

Pimtrea.................................... 85

Pindolol................................... 65

Pioglitazone HCl..................... 59

Pioglitazone HCl-Glimepiride

...............................................59

Pioglitazone HCl-Metformin HCl

...............................................60

Piperacillin-Tazobactam.........36

Piqray.......................................49

Pirmella 1/35...........................85

Piroxicam................................ 29

Plasma-Lyte 148..................... 76

Plasma-Lyte A......................... 76

Plenamine............................... 76

Podofilox................................. 74

Polymyxin B Sulfate................33

Polymyxin B-Trimethoprim.... 95

Pomalyst..................................46

Portia-28.................................. 85

Posaconazole......................... 43

Potassium Chloride................76

Potassium Chloride CR..........76

Potassium Chloride ER..........76

Potassium Chloride in Dextrose

...............................................76

Potassium Chloride in NaCl...76

Potassium Citrate ER............. 76

Praluent................................... 69

Pramipexole Dihydrochloride

...............................................51

Prasugrel HCl..........................63

Pravastatin Sodium................ 68

Praziquantel............................ 50

Prazosin HCl........................... 63

Pred Mild.................................96

Pred-G..................................... 94

Pred-G S.O.P...........................94

Prednicarbate......................... 73

23

Prednisolone...........................81

Prednisolone Acetate.............96

Prednisolone Sodium

Phosphate...................... 81, 96

Prednisone..............................81

Prednisone Intensol............... 81

Pregabalin............................... 70

Premarin..................................85

Premasol................................. 76

Premphase..............................85

Prempro.................................. 85

Prevalite...................................69

Previfem.................................. 85

Prezcobix................................ 57

Prezista....................................57

Priftin....................................... 45

Prilosec....................................79

Primaquine Phosphate...........51

Primidone................................39

Privigen....................................89

ProAir HFA.............................. 98

ProAir RespiClick................... 98

Probenecid..............................44

Probenecid-Colchicine...........44

Procalamine............................ 76

Prochlorperazine.................... 42

Prochlorperazine Maleate......42

Procrit...................................... 63

Procto-Med HC....................... 93

Procto-Pak...............................93

Proctosol HC...........................93

Proctozone-HC....................... 93

Procysbi...................................80

Progesterone Micronized...... 87

Prograf.....................................91

Prolastin-C...............................80

Prolensa.................................. 96

Prolia........................................93

Promacta.................................63

Promethazine HCl.................. 43

Promethegan.......................... 43

Propafenone HCl.................... 64

Propafenone HCl ER..............64

Proparacaine HCl................... 94

Propranolol HCl...................... 65

Propranolol HCl ER................ 65

Propranolol-HCTZ...................67

Propylthiouracil.......................88

ProQuad.................................. 92

Prosol...................................... 77

Protriptyline HCl......................42

Pulmozyme............................. 99

Purixan.................................... 46

Pyrazinamide.......................... 45

Pyridostigmine Bromide........ 45

Pyridostigmine Bromide ER

...............................................45

Pyrimethamine........................51

Q

Qinlock.................................... 46

Quadracel................................92

Quetiapine Fumarate..............53

Quetiapine Fumarate ER........53

Quinapril HCl...........................64

Quinapril-Hydrochlorothiazide

...............................................67

Quinidine Gluconate ER........ 64

Quinidine Sulfate.................... 64

Quinine Sulfate....................... 51

R

RabAvert................................. 92

Rabeprazole Sodium..............79

Raloxifene HCl........................ 87

Ramelteon.............................100

Ramipril................................... 64

Ranolazine ER........................ 67

Rasagiline Mesylate............... 51

Rasuvo.....................................91

RAVICTI...................................80

Rayaldee................................. 93

Rebif........................................ 71

Rebif Rebidose.......................71

Rebif Rebidose Titration Pack

...............................................71

Rebif Titration Pack................71

Reclipsen................................ 85

Recombivax HB......................92

Rectiv.......................................69

Regranex.................................74

Relenza Diskhaler...................57

Relistor.................................... 78

Repaglinide.............................60

Repatha...................................69

Repatha Pushtronex System

...............................................69

Repatha SureClick................. 69

Restasis Single-Use Vials.......94

Retacrit.................................... 63

Retevmo.................................. 46

Revlimid...................................46

Rexulti......................................53

Reyataz....................................57

Rhopressa...............................96

Ribavirin.................................. 55

24

Ridaura....................................89

Rifabutin..................................45

Rifampin.................................. 45

Riluzole....................................70

Rimantadine HCl.................... 58

Riomet ER............................... 60

Risedronate Sodium.............. 93

Risperdal Consta.................... 53

Risperidone.............................53

Risperidone ODT....................54

Ritonavir.................................. 57

Rivastigmine........................... 40

Rivastigmine Tartrate............. 40

Rivelsa..................................... 85

Rizatriptan Benzoate..............44

Rizatriptan Benzoate ODT..... 44

Rocklatan................................ 94

Ropinirole HCl........................ 51

Rosuvastatin Calcium............ 68

Rotarix..................................... 92

RotaTeq...................................92

Roweepra................................38

Roweepra XR..........................38

Rozlytrek................................. 49

Rubraca...................................49

Ruconest................................. 88

Rybelsus..................................60

Rydapt..................................... 49

Rytary.......................................51

S

Sancuso.................................. 43

Sandimmune...........................91

Santyl.......................................74

Saphris.................................... 54

Savella..................................... 70

Savella Titration Pack.............70

Scopolamine...........................43

Secuado.................................. 54

Selegiline HCl......................... 51

Selenium Sulfide.....................73

Selzentry..................................57

Serevent Diskus......................98

Serostim.................................. 82

Sertraline HCl..........................42

Setlakin....................................85

Sevelamer Carbonate............ 77

Sharobel..................................87

Shingrix................................... 92

Signifor.................................... 88

Sildenafil Citrate..................... 99

Silodosin..................................81

Silver Sulfadiazine.................. 74

Simbrinza................................ 96

Simponi................................... 91

Simvastatin..............................68

Sirolimus................................. 91

Sirturo......................................45

Sodium Chloride.....................77

Sodium Fluoride..................... 77

Sodium Phenylbutyrate..........80

Sodium Polystyrene Sulfonate

...............................................77

Sofosbuvir-Velpatasvir............55

Solifenacin Succinate.............80

Soliqua.................................... 60

Soltamox................................. 46

Somatuline Depot...................88

Somavert................................. 88

Sotalol HCl.............................. 64

Sotalol HCl AF.........................64

Sovaldi.....................................55

Spiriva HandiHaler..................98

Spiriva Respimat.....................98

Spironolactone....................... 67

Spironolactone-HCTZ............ 67

Sprintec 28..............................85

Spritam ODT........................... 38

Sprycel.....................................49

SPS.......................................... 77

Sronyx......................................85

SSD..........................................74

Stavudine................................ 56

Stelara..................................... 89

Stiolto Respimat................... 100

Stivarga....................................49

Streptomycin Sulfate..............33

Stribild..................................... 55

Suboxone................................32

Sucraid.................................... 80

Sucralfate................................ 79

Sulfacetamide Sodium...........95

Sulfacetamide-Prednisolone

...............................................94

Sulfadiazine.............................37

Sulfamethoxazole-

Trimethoprim........................37

Sulfamylon.............................. 75

Sulfasalazine.....................92, 93

Sulindac.................................. 29

Sumatriptan.............................44

Sumatriptan Succinate...........44

Sumatriptan Succinate Refill

...............................................44

25

Suprax..................................... 35

Suprep Bowel Prep Kit...........79

Sutent...................................... 49

Syeda.......................................85

Sylatron................................... 90

Symbicort..............................100

Symfi........................................56

Symfi Lo.................................. 56

SymlinPen 120........................60

SymlinPen 60..........................60

Sympazan................................39

Symtuza...................................57

Synarel.....................................88

Synjardy...................................60

Synjardy XR.............................60

Synribo.................................... 46

Synthroid................................. 87

T

Tabloid.....................................46

Tabrecta.................................. 46

Tacrolimus........................ 73, 91

Tadalafil...................................99

Tafinlar.....................................49

Tagrisso...................................49

Talzenna..................................49

Tamoxifen Citrate................... 46

Tamsulosin HCl...................... 81

Targretin..................................50

Tarina 24 Fe............................ 85

Tarina Fe 1/20 EQ.................. 86

Tasigna....................................49

Tazarotene.............................. 71

Tazicef..................................... 35

Taztia XT..................................65

Tazverik................................... 47

TDVAX..................................... 92

Tecfidera................................. 71

Tecfidera Starter Pack........... 71

Tegsedi....................................80

Telmisartan............................. 64

Telmisartan-Amlodipine......... 67

Telmisartan-HCTZ.................. 67

Temazepam.......................... 100

Tenivac.................................... 92

Tenofovir Disoproxil Fumarate

...............................................56

Terazosin HCl......................... 81

Terbinafine HCl.......................44

Terconazole............................ 44

Teriparatide.............................93

Testosterone...........................82

Testosterone Cypionate.........82

Testosterone Enanthate.........82

Tetrabenazine......................... 70

Tetracycline HCl..................... 37

Thalomid................................. 46

Theophylline........................... 99

Theophylline ER..................... 99

Thioridazine HCl..................... 52

Thiothixene............................. 52

Tiadylt ER................................ 65

Tiagabine HCl......................... 39

Tibsovo....................................49

Tigecycline..............................33

Timolol Maleate................45, 96

Timolol Maleate Ophthalmic

Gel Forming..........................96

Tinidazole................................33

Tivicay......................................55

Tizanidine HCl.........................54

TOBI Podhaler........................ 99

TobraDex.................................94

TobraDex ST...........................94

Tobramycin.......................95, 99

Tobramycin Sulfate................ 33

Tobramycin-Dexamethasone

...............................................94

Tobrex..................................... 95

Tolcapone............................... 51

Tolterodine Tartrate ER..........80

Topiramate..............................38

Toremifene Citrate..................46

Torsemide............................... 67

Toujeo Max SoloStar..............61

Toujeo SoloStar...................... 61

TPN Electrolytes..................... 77

Tracleer................................... 99

Tradjenta................................. 60

Tramadol HCl..........................31

Tramadol HCl ER....................30

Tramadol-Acetaminophen..... 31

Trandolapril.............................64

Tranexamic Acid.....................63

Transderm-Scop.....................43

Tranylcypromine Sulfate........41

Travasol...................................77

Travoprost............................... 97

Trazodone HCl........................42

Trecator...................................45

Trelegy Ellipta....................... 100

Trelstar Mixject....................... 88

Tresiba.....................................61

Tresiba FlexTouch..................61

26

Tretinoin............................ 50, 72

Tretinoin Microsphere............72

Trexall...................................... 91

Tri-Estarylla..............................86

Tri-Legest Fe........................... 86

Tri-Lo-Estarylla........................ 86

Tri-Lo-Sprintec........................ 86

Tri-Mili...................................... 86

Tri-Previfem............................. 86

Tri-Sprintec..............................86

Tri-VyLibra............................... 86

Tri-VyLibra Lo..........................86

Triamcinolone Acetonide......71,

73

Triamterene.............................67

Triamterene-HCTZ..................67

Triderm....................................73

Trientine HCl........................... 77

Trifluoperazine HCl.................52

Trifluridine............................... 95

Trihexyphenidyl HCl............... 51

TriLyte......................................79

Trimethoprim.......................... 33

Trimipramine Maleate............ 42

Trintellix................................... 42

Triumeq................................... 56

Trivora......................................86

TrophAmine............................ 77

Trulicity....................................60

Trumenba................................92

Truvada................................... 56

Tukysa..................................... 47

Turalio......................................49

Twinrix..................................... 92

Tybost......................................57

Tykerb......................................49

Tymlos..................................... 93

Typhim Vi................................ 92

U

Udenyca.................................. 63

Unithroid..................................87

Ursodiol................................... 79

V

Valacyclovir HCl......................55

Valchlor................................... 46

Valganciclovir HCl.................. 54

Valproic Acid...........................38

Valsartan..................................64

Valsartan-Hydrochlorothiazide

...............................................67

Valtoco 10 MG Dose.............. 39

Valtoco 15 MG Dose.............. 39

Valtoco 20 MG Dose.............. 39

Valtoco 5 MG Dose................ 39

Vancomycin HCl..................... 34

Vandazole................................34

VAQTA.....................................92

Varivax..................................... 92

Varizig......................................89

Vascepa...................................69

Velivet...................................... 86

Velphoro..................................77

Veltassa................................... 77

Vemlidy....................................55

Venclexta.................................49

Venclexta Starting Pack.........49

Venlafaxine HCl...................... 42

Venlafaxine HCl ER................ 42

Ventavis................................... 99

Verapamil HCl.........................66

Verapamil HCl ER...................66

Versacloz.................................54

Verzenio.................................. 49

Vibramycin.............................. 37

Victoza.....................................60

Vienva...................................... 86

Vigabatrin................................ 39

Vigadrone................................39

Viibryd......................................42

Viibryd Starter Pack................42

Vimpat..................................... 40

Viracept................................... 57

Viread...................................... 56

Vitrakvi...............................49, 50

Vivitrol......................................32

Vizimpro.................................. 50

Voriconazole........................... 44

Vosevi...................................... 55

Votrient.................................... 50

VP-PNV-DHA........................... 77

Vraylar......................................54

Vyfemla....................................86

VyLibra.................................... 86

Vyndamax............................... 80

Vyndaqel................................. 80

Vyvanse................................... 69

Vyzulta..................................... 97

W

Warfarin Sodium.....................62

Wixela Inhub......................... 100

WYMZYA Fe............................86

X

Xalkori......................................50

27

Xarelto..................................... 62

Xarelto Starter Pack............... 62

Xatmep.................................... 91

Xcopri................................ 38, 39

Xeljanz..................................... 89

Xeljanz XR............................... 89

Xgeva.......................................93

Xifaxan.....................................34

Xigduo XR............................... 60

Xiidra........................................94

Xofluza.....................................58

Xolair........................................89

Xospata................................... 50

Xpovio......................................47

Xtampza ER............................ 30

Xtandi.......................................46

Xulane......................................86

Xyrem.................................... 101

Y

YF-Vax......................................92

Yuvafem...................................86

Z

Zafirlukast................................97

Zaleplon................................ 100

Zarah....................................... 86

Zarxio.......................................63

Zejula.......................................50

Zelapar ODT........................... 52

Zelboraf................................... 50

Zemaira................................... 80

Zenatane................................. 72

Zenpep.................................... 80

Zerbaxa................................... 35

Zidovudine........................ 56, 57

Zileuton ER............................. 98

Ziprasidone HCl......................54

Ziprasidone Mesylate.............54

Zirgan...................................... 54

Zolinza..................................... 47

Zolpidem Tartrate.................100

Zonisamide............................. 40

Zorbtive................................... 82

Zortress................................... 91

Zostavax.................................. 92

Zovia 1/35E.............................86

Zyclara Pump..........................74

Zydelig.....................................50

Zyflo.........................................98

Zykadia....................................50

Zyprexa Relprevv....................54

28

Covered drugs by medical condition

The list below has information about the drugs covered by this plan. If you have trouble finding your

drug, turn to the “Covered drugs by name (Drug index)” on pages 12-28.

The first column lists the drug name, which may include the dosage form and strength. Brand

name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain

type (for example, Simvastatin). The information in the “Coverage Rules or limits on use” column

lists any special requirements for coverage of your drug. If quantity limits (QL) apply to a drug, the

restriction amounts are shown in the chart on pages 102-132.

Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

A1

AnalgesicsB1

Nonsteroidal Anti-inflammatory DrugsC1

Celecoxi

b

Celecoxib (Oral Capsule) G 3 QL C1

Dicl

ofen

ac Epol

amine Diclofenac Epolamine (Transdermal Patch) G 4 PA; QL C1

Dicl

ofenac

Potassiu

m Diclofenac Potassium (Oral Tablet) G 2 ¨C1

Dicl

ofenac

Sodium

ER Diclofenac Sodium ER (Oral Tablet Extended Release 24 Hour)

G 2 ¨C1

Diclofen

ac Sodi

um Diclofenac Sodium (Oral Tablet Delayed Release) G 2 ¨C1

Dicl

ofen

ac Sodi

um Diclofenac Sodium (1% Transdermal Gel) G 3

C1

Diflu

nisal

Diflunisal (Oral Tablet) G 3

C1

Eto

dolac

ER

Etodolac ER (Oral Tablet Extended Release 24 Hour) G 4

C1

Etodola

c

Etodolac (Oral Capsule) G 3

C1

Etodola

c

Etodolac (Oral Tablet Immediate Release) G 3

C1

Flur

biprofen

Flurbiprofen (100MG Oral Tablet) G 2 ¨C1

Ibu

Ibu (600MG Oral Tablet, 800MG Oral Tablet) G 2 ¨C1

Ibuprofe

n

Ibuprofen (Oral Suspension) G 2 ¨C1

Ibuprofe

n

Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet,

800MG Oral Tablet)G 2 ¨

C1

Indo

met

hacin

Indomethacin (25MG Oral Capsule Immediate Release,

50MG Oral Capsule Immediate Release)G 2 ¨

C1

Ket

oprofen

Ketoprofen (Oral Capsule Immediate Release) G 3

C1

Mel

oxicam

Meloxicam (Oral Tablet) G 1 ¨C1

Nabume

tone

Nabumetone (Oral Tablet) G 2 ¨C1

Naproxe

n DR

Naproxen DR (Oral Tablet Delayed Release) (Generic

EC-Naprosyn)G 2 ¨

C1

Nap

roxen

Naproxen (Oral Suspension) G 5 DL C1

Nap

roxen

Naproxen (Oral Tablet Immediate Release) G 2 ¨C1

Piroxica

m

Piroxicam (Oral Capsule) G 3

C1

Sulinda

c

Sulindac (Oral Tablet) G 2 ¨

29

Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

B1

Opioid Analgesics, Long-actingC1

Bupreno

rphine

Buprenorphine (Transdermal Patch Weekly) G 4 7D; DL; QL C1

Fent

anyl

Fentanyl (100MCG/HR Transdermal Patch 72 Hour,

12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR

Transdermal Patch 72 Hour, 50MCG/HR Transdermal

Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

G 4 7D; MME; DL; QL

C1

Hyd

romorph

one HCl

ER Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)

G 4 7D; MME; DL; QL C1

Levorph

anol

Tartr

ate Levorphanol Tartrate (Oral Tablet) G 5 7D; MME; DL; QL C1

Methad

one HCl

Methadone HCl (Oral Solution) G 3 7D; MME; DL; QL C1

Met

had

one HCl

Methadone HCl (Oral Tablet) G 3 7D; MME; DL; QL C1

Mor

phine

Sulf

ate ER Morphine Sulfate ER (100MG Oral Tablet Extended

Release, 15MG Oral Tablet Extended Release, 30MG

Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)

G 3 7D; MME; DL; QL

C1

Mor

phine

Sulfate

ER Morphine Sulfate ER (200MG Oral Tablet Extended

Release) (Generic MS Contin)G 4 7D; MME; DL; QL

C1

Nucynta

ER

Nucynta ER (Oral Tablet Extended Release 12 Hour) B 3 7D; MME; DL; QL C1

Tramad

ol HCl

ER Tramadol HCl ER (Biphasic) (Oral Tablet Extended

Release 24 Hour)G 3 7D; MME; DL; QL

C1

Tra

madol

HCl

ER Tramadol HCl ER (Oral Tablet Extended Release 24

Hour)G 3 7D; MME; DL; QL

C1

Xta

mpza

ER

Xtampza ER (Oral Capsule ER 12 Hour Abuse-

Deterrent)B 3 7D; MME; DL; QL

B1

Opioid Analgesics, Short-actingC1

Acetami

nophen-

Cod

eine Acetaminophen-Codeine (120-12MG/5ML Oral Solution) G 2 7D; MME; DL; QL ¨C1

Acet

ami

nophen-

Codeine Acetaminophen-Codeine (300-15MG Oral Tablet,

300-30MG Oral Tablet, 300-60MG Oral Tablet)G 2 7D; MME; DL; QL ¨

C1

Buta

lbital-

Acet

aminop

hen-Caff

eine Butalbital-Acetaminophen-Caffeine (Oral Tablet) G 3 QL C1

Buta

lbital-

Aspirin-

Caffeine Butalbital-Aspirin-Caffeine (Oral Capsule) G 3 QL C1

Butorph

anol

Tartr

ate Butorphanol Tartrate (Nasal Solution) G 3 7D; MME; DL; QL C1

Cod

eine

Sulf

ate Codeine Sulfate (15MG Oral Tablet) B 4 7D; MME; DL; QL C1

Cod

eine

Sulf

ate Codeine Sulfate (30MG Oral Tablet, 60MG Oral Tablet) G 4 7D; MME; DL; QL C1

Dur

amorph

Duramorph (Injection Solution) B 4 DL C1

Endocet

Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

G 3 7D; MME; DL; QL

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6 - 7.

30 Last updated September 1, 2020

Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Fentanyl

Citra

te

Fentanyl Citrate (1200MCG Buccal Lozenge On A

Handle, 1600MCG Buccal Lozenge On A Handle, 400MCG Buccal Lozenge On A Handle, 600MCG Buccal

Lozenge On A Handle, 800MCG Buccal Lozenge On A

Handle)

G 5 PA; DL; QL

C1

Fentanyl

Citrate

Fentanyl Citrate (200MCG Buccal Lozenge On A Handle) G 4 PA; DL; QL C1

Hyd

roco

done-

Acetami

nophen Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral

Solution)G 3 7D; MME; DL; QL

C1

Hyd

rocodon

e-Acet

ami

nophen Hydrocodone-Acetaminophen (10-325MG Oral Tablet,

5-325MG Oral Tablet, 7.5-325MG Oral Tablet)G 3 7D; MME; DL; QL

C1

Hydroco

don

e-Ibup

rofen Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet) G 3 7D; MME; DL; QL C1

Hydrom

orphone

HCl Hydromorphone HCl (1MG/ML Oral Liquid) G 4 7D; MME; DL; QL C1

Hyd

rom

orphone

HCl Hydromorphone HCl (2MG Oral Tablet Immediate

Release, 4MG Oral Tablet Immediate Release, 8MG Oral Tablet Immediate Release)

G 2 7D; MME; DL; QL ¨

C1

Hyd

romorph

one

HCl Pres

ervative

Free Hydromorphone HCl Preservative Free (10MG/ML

Injection Solution, 50MG/5ML Injection Solution)G 4 DL

C1

Lorc

et HD

Lorcet HD (Oral Tablet) G 3 7D; MME; DL; QL C1

Lorcet

Lorcet (Oral Tablet) G 3 7D; MME; DL; QL C1

Lorcet

Plus

Lorcet Plus (7.5-325MG Oral Tablet) G 3 7D; MME; DL; QL C1

Mor

phine

Sulf

ate Morphine Sulfate (Oral Solution) G 3 7D; MME; DL; QL C1

Mor

phine

Sulfate Morphine Sulfate (Oral Tablet Immediate Release) G 3 7D; MME; DL; QL C1

Oxycod

one

HCl

Oxycodone HCl (100MG/5ML Oral Concentrate) G 4 7D; MME; DL; QL C1

Oxycod

one HCl

Oxycodone HCl (5MG/5ML Oral Solution) G 4 7D; MME; DL; QL C1

Oxy

cod

one HCl

Oxycodone HCl (10MG Oral Tablet Immediate Release,

15MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate

Release, 5MG Oral Tablet Immediate Release)

G 2 7D; MME; DL; QL ¨

C1

Oxy

codone-

Acet

aminop

hen Oxycodone-Acetaminophen (10-325MG Oral Tablet,

2.5-325MG Oral Tablet, 5-325MG Oral Tablet,

7.5-325MG Oral Tablet)

G 3 7D; MME; DL; QL

C1

Oxy

codone-

Aspirin Oxycodone-Aspirin (Oral Tablet) G 3 7D; MME; DL; QL C1

Tramad

ol HCl

Tramadol HCl (50MG Oral Tablet Immediate Release) G 2 7D; MME; DL; QL ¨C1

Tra

mad

ol-Acet

aminop

hen Tramadol-Acetaminophen (Oral Tablet) G 2 7D; MME; DL; QL ¨A1

AnestheticsB1

Local AnestheticsC1

Lidocain

e

Lidocaine (5% External Ointment) G 4 QL C1

Lidocain

e

Lidocaine (5% External Patch) G 4 PA; QL C1

Lido

cain

e HCl

Lidocaine HCl (4% External Solution) G 4

Last updated September 1, 2020 31

Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lidocain

e

HCl

Lidocaine HCl (External Gel) G 2 ¨C1

Lidocain

e Visc

ous Lidocaine Viscous (2% Mouth/Throat Solution) G 2 ¨C1

Lido

cain

e-Prilo

caine Lidocaine-Prilocaine (External Cream) G 3

A1

Anti-Addiction/Substance Abuse Treatment AgentsB1

Alcohol Deterrents/Anti-cravingC1

Acampr

osate

Calc

ium Acamprosate Calcium (Oral Tablet Delayed Release) G 4

C1

Disu

lfira

m

Disulfiram (Oral Tablet) G 3

C1

Nalt

rexone

HCl

Naltrexone HCl (Oral Tablet) G 3

C1

Vivit

rol

Vivitrol (Intramuscular Suspension Reconstituted) B 5 DL B1

Opioid DependenceC1

Bupreno

rphine

HCl Buprenorphine HCl (Tablet Sublingual) G 2 QL ¨C1

Bup

renorphi

ne

HCl-Nalo

xone

HCl Buprenorphine HCl-Naloxone HCl (Sublingual Film) G 4 QL C1

Bup

renorphi

ne HCl-

Nalo

xone

HCl Buprenorphine HCl-Naloxone HCl (Tablet Sublingual) G 2 QL ¨C1

Suboxo

ne

Suboxone (Sublingual Film) B 4 QL B1

Opioid Reversal AgentsC1

Nalo

xon

e HCl

Naloxone HCl (0.4MG/ML Injection Solution) G 2 ¨C1

Nalo

xone

HCl

Naloxone HCl (Injection Solution Cartridge) G 2 ¨C1

Nalo

xone

HCl

Naloxone HCl (Injection Solution Prefilled Syringe) G 2 ¨C1

Narcan

Narcan (Nasal Liquid) B 3

B1

Smoking Cessation AgentsC1

Bup

ropion

HCl

SR Bupropion HCl SR (150MG Oral Tablet Extended

Release 12 Hour Smoking-Deterrent)G 2 ¨

C1

Cha

ntix Con

tinuing

Mon

th Pak Chantix Continuing Month Pak (Oral Tablet) B 3

C1

Chantix

Chantix (Oral Tablet) B 3

C1

Chantix

Starting

Mon

th Pak Chantix Starting Month Pak (Oral Tablet) B 3

C1

Nico

trol

Nicotrol (Inhalation Inhaler) B 4

C1

Nico

trol NS

Nicotrol NS (Nasal Solution) B 4

A1

AntibacterialsB1

AminoglycosidesC1

Ami

kaci

n Sulf

ate Amikacin Sulfate (500MG/2ML Injection Solution) G 4

C1

Gen

tamicin

Sulf

ate-0.9

% Sodi

um Chlo

ride

Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous

Solution)G 4

C1

Gen

tamicin

Sulfate Gentamicin Sulfate (40MG/ML Injection Solution) G 4

C1

Neomyci

n

Sulfate Neomycin Sulfate (Oral Tablet) G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Paromo

myci

n Sulf

ate Paromomycin Sulfate (Oral Capsule) G 4

C1

Strepto

mycin

Sulfate Streptomycin Sulfate (Intramuscular Solution

Reconstituted)G 5 DL

C1

Tob

ram

ycin Sulf

ate Tobramycin Sulfate (10MG/ML Injection Solution,

80MG/2ML Injection Solution)G 4

B1

Antibacterials, OtherC1

Aztreon

am

Aztreonam (1GM Injection Solution Reconstituted) G 4

C1

Clindam

ycin HCl

Clindamycin HCl (Oral Capsule) G 2 ¨C1

Clin

dam

ycin Pal

mitate

HCl Clindamycin Palmitate HCl (Oral Solution Reconstituted) G 4

C1

Clin

damycin

Pho

sphate

in D5

W Clindamycin Phosphate in D5W (Intravenous Solution) G 4

C1

Clin

damycin

Phosph

ate Clindamycin Phosphate (300MG/2ML Injection Solution,

600MG/4ML Injection Solution, 900MG/6ML Injection Solution)

G 4

C1

Clindam

ycin

Phosph

ate Clindamycin Phosphate (Vaginal Cream) G 3

C1

Colistim

ethate

Sodium Colistimethate Sodium (CBA) (Injection Solution

Reconstituted)G 5 DL

C1

Dalv

ance

Dalvance (Intravenous Solution Reconstituted) B 5 PA; DL C1

Dap

tomycin

Daptomycin (Intravenous Solution Reconstituted) G 5 DL C1

Linezoli

d

Linezolid (Intravenous Solution) G 4

C1

Linezoli

d

Linezolid (Oral Suspension Reconstituted) G 5 DL C1

Line

zoli

d

Linezolid (Oral Tablet) G 4 QL C1

Met

henami

ne

Hippura

te Methenamine Hippurate (Oral Tablet) G 3

C1

Metr

onidazol

e

Metronidazole (0.75% External Cream) G 4

C1

Metronid

azole

Metronidazole (0.75% External Gel, 1% External Gel) G 4

C1

Metr

onid

azole

Metronidazole (0.75% External Lotion) G 4

C1

Metr

onidazol

e in

NaCl

0.79% Metronidazole in NaCl 0.79% (Intravenous Solution) G 4

C1

Metr

onidazol

e

Metronidazole (250MG Oral Tablet, 500MG Oral Tablet) G 2 ¨C1

Metronid

azol

e

Metronidazole (0.75% Vaginal Gel) G 3

C1

Nitrofur

antoin

Mac

rocrystal Nitrofurantoin Macrocrystal (100MG Oral Capsule,

50MG Oral Capsule) (Generic Macrodantin)G 3

C1

Nitr

ofur

antoin

Monohy

drate Nitrofurantoin Monohydrate (Generic Macrobid) G 3

C1

Nitr

ofuranto

in

Nitrofurantoin (Oral Suspension) G 4

C1

Polymyxi

n B

Sulfate Polymyxin B Sulfate (Injection Solution Reconstituted) G 4

C1

Tigecycli

ne

Tigecycline (Intravenous Solution Reconstituted) G 5 DL C1

Tini

daz

ole

Tinidazole (Oral Tablet) G 4

C1

Trim

ethoprim

Trimethoprim (Oral Tablet) G 2 ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Vancom

ycin

HCl

Vancomycin HCl (10GM Intravenous Solution

Reconstituted, 1GM Intravenous Solution Reconstituted, 500MG Intravenous Solution Reconstituted, 750MG

Intravenous Solution Reconstituted)

G 4

C1

Vancom

ycin HCl

Vancomycin HCl (250MG Intravenous Solution

Reconstituted)B 4

C1

Van

com

ycin HCl

Vancomycin HCl (Oral Capsule) G 4 QL C1

Van

dazole

Vandazole (Vaginal Gel) B 3

C1

Xifaxan

Xifaxan (Oral Tablet) B 5 PA; DL B1

Beta-lactam, CephalosporinsC1

Cefa

clor

Cefaclor (Oral Capsule) G 3

C1

Cefa

droxil

Cefadroxil (Oral Capsule) G 2 ¨C1

Cefa

droxil

Cefadroxil (Oral Suspension Reconstituted) G 2 ¨C1

Cefazolin

Sodium Cefazolin Sodium (10GM Injection Solution

Reconstituted, 1GM Injection Solution Reconstituted,

500MG Injection Solution Reconstituted)

G 4

C1

Cefdinir

Cefdinir (Oral Capsule) G 3

C1

Cef

dinir

Cefdinir (Oral Suspension Reconstituted) G 3

C1

Cef

epime

HCl

Cefepime HCl (Injection Solution Reconstituted) G 4

C1

Cefixim

e

Cefixime (Oral Capsule) G 3

C1

Cefixim

e

Cefixime (Oral Suspension Reconstituted) G 4

C1

Cef

otet

an Diso

dium Cefotetan Disodium (Injection Solution Reconstituted) G 4

C1

Cef

oxitin

Sodi

um Cefoxitin Sodium (Injection Solution Reconstituted) G 4

C1

Cef

oxitin

Sodium Cefoxitin Sodium (Intravenous Solution Reconstituted) G 4

C1

Cefpod

oxime

Prox

etil Cefpodoxime Proxetil (Oral Suspension Reconstituted) G 4

C1

Cef

pod

oxime

Proxetil Cefpodoxime Proxetil (Oral Tablet) G 4

C1

Cef

prozil

Cefprozil (Oral Suspension Reconstituted) G 3

C1

Cef

prozil

Cefprozil (Oral Tablet) G 3

C1

Ceftazidi

me

Ceftazidime (Injection Solution Reconstituted) G 4

C1

Ceftriax

one Sodi

um Ceftriaxone Sodium (1GM Injection Solution

Reconstituted, 250MG Injection Solution Reconstituted,

2GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)

G 4

C1

Ceft

riax

one Sodi

um Ceftriaxone Sodium (10GM Intravenous Solution

Reconstituted)G 4

C1

Cef

uroxime

Axetil Cefuroxime Axetil (Oral Tablet) G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Cefurox

ime

Sodium Cefuroxime Sodium (Injection Solution Reconstituted) G 4

C1

Cefurox

ime Sodi

um Cefuroxime Sodium (Intravenous Solution Reconstituted)

G 4

C1

Cep

hale

xin

Cephalexin (250MG Oral Capsule, 500MG Oral Capsule) G 2 ¨C1

Cep

halexin

Cephalexin (750MG Oral Capsule) G 3

C1

Cephale

xin

Cephalexin (Oral Suspension Reconstituted) G 2 ¨C1

Suprax

Suprax (Oral Capsule) B 3

C1

Sup

rax

Suprax (500MG/5ML Oral Suspension Reconstituted) B 3

C1

Sup

rax

Suprax (Oral Tablet Chewable) G 3

C1

Tazi

cef

Tazicef (Injection Solution Reconstituted) G 4

C1

Zerbax

a

Zerbaxa (Intravenous Solution Reconstituted) B 5 PA; DL B1

Beta-lactam, PenicillinsC1

Am

oxicillin

Amoxicillin (Oral Capsule) G 1 ¨C1

Am

oxicillin

Amoxicillin (Oral Suspension Reconstituted) G 1 ¨C1

Amoxici

llin

Amoxicillin (Oral Tablet Immediate Release) G 1 ¨C1

Amoxici

llin

Amoxicillin (Oral Tablet Chewable) G 1 ¨C1

Am

oxici

llin-Pota

ssium

Clavulan

ate

ERAmoxicillin-Potassium Clavulanate ER (Oral Tablet

Extended Release 12 Hour)G 4

C1

Am

oxicillin-

Pota

ssium

Clavulan

ate Amoxicillin-Potassium Clavulanate (Oral Suspension Reconstituted)

G 2 ¨C1

Am

oxicillin-

Potassiu

m Clav

ulan

ate Amoxicillin-Potassium Clavulanate (Oral Tablet

Immediate Release)G 2 ¨

C1

Amoxici

llin-Pota

ssiu

m Clav

ulanate Amoxicillin-Potassium Clavulanate (Oral Tablet

Chewable)G 2 ¨

C1

Am

picill

in

Ampicillin (Oral Capsule) G 2 ¨C1

Am

picillin

Sodi

um Ampicillin Sodium (125MG Injection Solution Reconstituted, 1GM Injection Solution Reconstituted)

G 4

C1

Am

picillin

Sodium Ampicillin Sodium (10GM Intravenous Solution

Reconstituted)G 4

C1

Ampicill

in-

Sulbacta

m Sodi

um Ampicillin-Sulbactam Sodium (Injection Solution

Reconstituted)G 4

C1

Ampicill

in-Sulb

acta

m Sodi

um Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous

Solution Reconstituted)G 4

C1

Bicill

in C-

R 900/

300 Bicillin C-R 900/300 (Intramuscular Suspension) B 4

C1

Bicill

in C-R

Bicillin C-R (Intramuscular Suspension) B 4

C1

Bicillin L-

A

Bicillin L-A (Intramuscular Suspension) B 4

C1

Dicloxa

cillin

Sodi

um Dicloxacillin Sodium (Oral Capsule) G 2 ¨C1

Nafc

illin

Sodium

Nafcillin Sodium (1GM Injection Solution Reconstituted, 2GM Injection Solution Reconstituted)

G 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Nafcillin

Sodi

um

Nafcillin Sodium (10GM Intravenous Solution

Reconstituted)G 4

C1

Oxacillin

Sodi

um in

Dext

rose Oxacillin Sodium in Dextrose (Intravenous Solution) B 4

C1

Oxa

cillin

Sodi

um Oxacillin Sodium (Injection Solution Reconstituted) G 4

C1

Oxa

cillin

Sodium Oxacillin Sodium (Intravenous Solution Reconstituted) G 4

C1

Penicillin

G

Potassiu

m Penicillin G Potassium (20000000UNIT Injection Solution

Reconstituted)G 4

C1

Penicillin

G Proc

aine Penicillin G Procaine (Intramuscular Suspension) G 4

C1

Peni

cillin

G Sodi

um Penicillin G Sodium (Injection Solution Reconstituted) G 5 DL C1

Peni

cillin V

Pota

ssium Penicillin V Potassium (Oral Solution Reconstituted) G 2 ¨C1

Peni

cillin V

Potassiu

m Penicillin V Potassium (Oral Tablet) G 2 ¨C1

Piperacill

in-

Tazoba

ctam Piperacillin-Tazobactam (Intravenous Solution

Reconstituted)G 4

B1

CarbapenemsC1

Erta

penem

Sodi

um Ertapenem Sodium (Injection Solution Reconstituted) G 4

C1

Imip

enem-

Cilastati

n Imipenem-Cilastatin (Intravenous Solution Reconstituted) G 4

C1

Merope

nem

Meropenem (Intravenous Solution Reconstituted) G 4

B1

MacrolidesC1

Azit

hro

mycin

Azithromycin (Intravenous Solution Reconstituted) G 4

C1

Azit

hromyci

n

Azithromycin (Oral Suspension Reconstituted) G 1 ¨C1

Azit

hromyci

n

Azithromycin (Oral Tablet) G 1 ¨C1

Clarithro

mycin

ER Clarithromycin ER (Oral Tablet Extended Release 24 Hour)

G 3

C1

Clari

thro

mycin

Clarithromycin (Oral Suspension Reconstituted) G 4

C1

Clari

thromyci

n

Clarithromycin (Oral Tablet Immediate Release) G 3

C1

Dific

id

Dificid (Oral Tablet) B 5 DL C1

E.E.S.

Gra

nules E.E.S. Granules (Oral Suspension Reconstituted) B 4

C1

Erythroc

in Lact

obio

nate Erythrocin Lactobionate (Intravenous Solution Reconstituted)

G 4

C1

Eryt

hro

mycin

Base Erythromycin Base (Oral Capsule Delayed Release

Particles)G 4

C1

Eryt

hromyci

n Bas

e Erythromycin Base (Oral Tablet Immediate Release) G 4

C1

Erythro

myci

n Bas

e Erythromycin Base (Oral Tablet Delayed Release) G 4

C1

Erythro

mycin

Ethy

lsuccina

te Erythromycin Ethylsuccinate (200MG/5ML Oral

Suspension Reconstituted)G 4




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Erythro

myci

n Ethy

lsuccina

te Erythromycin Ethylsuccinate (Oral Tablet) G 4

B1

QuinolonesC1

Cipr

oflo

xacin

HCl Ciprofloxacin HCl (100MG Oral Tablet Immediate

Release)G 4

C1

Cipr

ofloxaci

n HCl Ciprofloxacin HCl (250MG Oral Tablet Immediate

Release, 500MG Oral Tablet Immediate Release, 750MG

Oral Tablet Immediate Release)

G 2 ¨

C1

Ciproflo

xaci

n in D5

W Ciprofloxacin in D5W (200MG/100ML Intravenous Solution)

G 4

C1

Levoflo

xacin in

D5

W Levofloxacin in D5W (500MG/100ML Intravenous

Solution, 750MG/150ML Intravenous Solution)G 4

C1

Lev

oflo

xacin

Levofloxacin (25MG/ML Intravenous Solution) G 4

C1

Lev

ofloxaci

n

Levofloxacin (25MG/ML Oral Solution) G 4

C1

Lev

ofloxaci

n

Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet,


C1

Moxiflox

acin

HCl in

NaCl Moxifloxacin HCl in NaCl (Intravenous Solution) G 4

C1

Moxiflox

acin HCl

Moxifloxacin HCl (Oral Tablet) G 3

C1

Oflo

xacin

Ofloxacin (Oral Tablet) G 3

B1

SulfonamidesC1

Sulfadia

zine

Sulfadiazine (Oral Tablet) G 4

C1

Sulfame

thoxazol

e-

Trimetho

prim Sulfamethoxazole-Trimethoprim (Oral Suspension) G 3

C1

Sulf

ame

thoxazol

e-Trim

ethoprim Sulfamethoxazole-Trimethoprim (Oral Tablet) G 2 ¨

B1

TetracyclinesC1

De

meclocy

cline HCl Demeclocycline HCl (Oral Tablet) G 4

C1

Doxy

100

Doxy 100 (Intravenous Solution Reconstituted) G 4

C1

Dox

ycyc

line Hycl

ate Doxycycline Hyclate (Oral Capsule) G 3

C1

Dox

ycycline

Hycl

ate Doxycycline Hyclate (100MG Oral Tablet Immediate

Release, 20MG Oral Tablet Immediate Release)G 3

C1

Dox

ycycline

Monohy

drat

e Doxycycline Monohydrate (100MG Oral Capsule, 50MG

Oral Capsule)G 3

C1

Doxycyc

line

Monohy

drate Doxycycline Monohydrate (Oral Suspension

Reconstituted)G 4

C1

Doxycyc

line Mon

ohy

drate Doxycycline Monohydrate (100MG Oral Tablet, 50MG

Oral Tablet, 75MG Oral Tablet)G 3

C1

Min

ocy

cline HCl

Minocycline HCl (Oral Capsule) G 2 ¨C1

Min

ocycline

HCl

Minocycline HCl (Oral Tablet Immediate Release) G 4

C1

Tetracyc

line

HCl

Tetracycline HCl (Oral Capsule) G 4

C1

Vibramy

cin

Vibramycin (50MG/5ML Oral Syrup) B 4

A1

Anticonvulsants


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

B1

Anticonvulsants, OtherC1

BRIVIA

CT

BRIVIACT (Oral Solution) B 5 PA; DL; QL C1

BRI

VIA

CT

BRIVIACT (Oral Tablet) B 5 PA; DL; QL C1

Epid

iolex

Epidiolex (Oral Solution) B 5 PA; DL C1

Felbama

te

Felbamate (Oral Suspension) G 5 DL C1

Felbama

te

Felbamate (Oral Tablet) G 4

C1

Fyc

omp

a

Fycompa (Oral Suspension) B 5 DL; QL C1

Fyc

ompa

Fycompa (10MG Oral Tablet, 12MG Oral Tablet, 4MG

Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet)B 5 DL; QL

C1

Fyc

ompa

Fycompa (2MG Oral Tablet) B 4 QL C1

Lamotrig

ine

Lamotrigine (100MG Oral Tablet Immediate Release,

150MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 25MG Oral Tablet Immediate

Release)

G 2 ¨

C1

Lamotrig

ine

Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral

Tablet Chewable)G 3

C1

Lev

etiraceta

m

ER Levetiracetam ER (Oral Tablet Extended Release 24 Hour)

G 3

C1

Lev

etiraceta

m

Levetiracetam (Oral Solution) G 2 ¨C1

Levetira

ceta

m

Levetiracetam (Oral Tablet Immediate Release) G 2 ¨C1

Roweepr

a

Roweepra (Oral Tablet Immediate Release) G 2 ¨C1

Row

eepr

a XR

Roweepra XR (Oral Tablet Extended Release 24 Hour) G 3

C1

Sprit

am ODT

Spritam ODT (Oral Tablet Disintegrating Soluble) B 4

C1

Topi

ramate

Topiramate (Oral Capsule Sprinkle Immediate Release) G 2 ¨C1

Topiram

ate

Topiramate (Oral Tablet) G 2 ¨C1

Valp

roic

Acid

Valproic Acid (Oral Capsule) G 2 ¨C1

Valp

roic Acid

Valproic Acid (Oral Solution) G 2 ¨C1

Xco

pri

Xcopri (250 MG Daily Dose) (Oral Tablet Therapy

Pack)B 5 PA; DL; QL

C1

Xcopri

Xcopri (350 MG Daily Dose) (Oral Tablet Therapy

Pack)B 5 PA; DL; QL

C1

Xcopri

Xcopri (100MG Oral Tablet, 150MG Oral Tablet,

50MG Oral Tablet)B 4 PA; QL

C1

Xco

pri

Xcopri (200MG Oral Tablet) B 5 PA; DL; QL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Xcopri

Xcopri (14x12.5MG & 14x25MG Oral Tablet Therapy

Pack)B 4 PA; QL

C1

Xcopri

Xcopri (14x150MG & 14x200MG Oral Tablet Therapy

Pack, 14x50MG & 14x100MG Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

B1

Calcium Channel Modifying AgentsC1

Celo

ntin

Celontin (Oral Capsule) B 4

C1

Ethosuxi

mid

e

Ethosuximide (Oral Capsule) G 3

C1

Ethosuxi

mide

Ethosuximide (Oral Solution) G 3

B1

Gamma-aminobutyric Acid (GABA) Augmenting AgentsC1

Clo

bazam

Clobazam (Oral Suspension) G 4 PA; QL C1

Clo

bazam

Clobazam (Oral Tablet) G 4 PA; QL C1

Diazepa

m

Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG

Rectal Gel)G 4 QL

C1

Gabape

ntin

Gabapentin (Oral Capsule) G 2 ¨C1

Gab

apentin

Gabapentin (250MG/5ML Oral Solution) G 3

C1

Gab

apentin

Gabapentin (Oral Tablet) G 2 ¨C1

Nayzila

m

Nayzilam (Nasal Solution) B 4 QL C1

Phenob

arbital

Phenobarbital (Oral Elixir) G 2 ¨C1

Phe

nob

arbital

Phenobarbital (Oral Tablet) G 2 ¨C1

Prim

idone

Primidone (Oral Tablet) G 2 ¨C1

Sym

pazan

Sympazan (10MG Oral Film, 20MG Oral Film) B 5 PA; DL; QL C1

Sympaz

an

Sympazan (5MG Oral Film) B 4 PA; QL C1

Tiag

abin

e HCl

Tiagabine HCl (Oral Tablet) G 4

C1

Valt

oco 10

MG

Dose Valtoco 10 MG Dose (Nasal Liquid) B 4 QL C1

Valt

oco 15

MG Dos

e Valtoco 15 MG Dose (Nasal Liquid Therapy Pack) B 4 QL C1

Valtoco

20

MG Dos

e Valtoco 20 MG Dose (Nasal Liquid Therapy Pack) B 4 QL C1

Valtoco

5 MG

Dos

e Valtoco 5 MG Dose (Nasal Liquid) B 4 QL C1

Viga

batri

n

Vigabatrin (Oral Packet) G 5 PA; LA; DL; QL C1

Viga

batrin

Vigabatrin (Oral Tablet) G 5 PA; LA; DL; QL C1

Vigadron

e

Vigadrone (Oral Packet) G 5 PA; LA; DL; QL B1

Sodium Channel AgentsC1

Apti

om

Aptiom (Oral Tablet) B 5 DL; QL C1

Ban

zel

Banzel (Oral Suspension) B 5 DL C1

Ban

zel

Banzel (Oral Tablet) B 5 DL C1

Carbam

aze

pine ER Carbamazepine ER (Oral Capsule Extended Release 12

Hour)G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Carbam

aze

pine ER Carbamazepine ER (Oral Tablet Extended Release 12

Hour)G 3

C1

Carbam

azepine

Carbamazepine (Oral Suspension) G 3

C1

Car

bam

azepine

Carbamazepine (Oral Tablet Immediate Release) G 3

C1

Car

bamaze

pine

Carbamazepine (Oral Tablet Chewable) G 3

C1

Dilantin

INF

ATABS Dilantin INFATABS (Oral Tablet Chewable) G 3

C1

Dilantin

Dilantin (Oral Capsule) G 3

C1

Epit

ol

Epitol (Oral Tablet) G 3

C1

Oxc

arbazepi

ne

Oxcarbazepine (300MG/5ML Oral Suspension) G 4

C1

Oxc

arbazepi

ne

Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet,

600MG Oral Tablet)G 3

C1

Pegano

ne

Peganone (Oral Tablet) B 4

C1

Phenyte

k

Phenytek (Oral Capsule) G 2 ¨C1

Phe

nytoin

Phenytoin (125MG/5ML Oral Suspension) G 2 ¨C1

Phe

nytoin

Phenytoin (Oral Tablet Chewable) G 2 ¨C1

Phenyto

in

Sodium

Extende

d Phenytoin Sodium Extended (Oral Capsule) G 2 ¨C1

Vimpat

Vimpat (Oral Solution) B 4 QL C1

Vim

pat

Vimpat (Oral Tablet) B 4 QL C1

Zoni

samide

Zonisamide (Oral Capsule) G 2 ¨A1

Antidementia AgentsB1

Antidementia Agents, OtherC1

Na

mza

ric

Namzaric (Oral Capsule ER 24 Hour Therapy Pack) B 3 PA; QL C1

Na

mzaric

Namzaric (Oral Capsule Extended Release 24 Hour) B 3 PA; QL B1

Cholinesterase InhibitorsC1

Donepe

zil

HCl

Donepezil HCl (Oral Tablet) G 1 QL ¨C1

Donepe

zil HCl

ODT Donepezil HCl ODT (Oral Tablet Dispersible) G 2 QL ¨C1

Gala

nta

mine

Hydrobr

omide

ER Galantamine Hydrobromide ER (Oral Capsule Extended

Release 24 Hour)G 4 QL

C1

Gala

ntamin

e Hyd

robr

omide Galantamine Hydrobromide (Oral Solution) G 4 QL C1

Galanta

min

e Hyd

robromi

de Galantamine Hydrobromide (Oral Tablet) G 4 QL C1

Rivastig

mine

Tartr

ate Rivastigmine Tartrate (Oral Capsule) G 3 QL C1

Riva

stig

mine

Rivastigmine (Transdermal Patch 24 Hour) G 4 ST; QL B1

N-methyl-D-aspartate (NMDA) Receptor AntagonistC1

Me

mantine

HCl ER Memantine HCl ER (Oral Capsule Extended Release 24

Hour)G 3 PA; QL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Meman

tine

HCl

Memantine HCl (2MG/ML Oral Solution) G 4 PA; QL C1

Meman

tine HCl

Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet) G 2 PA; QL ¨C1

Me

man

tine HCl

Titration

Pak Memantine HCl Titration Pak (Oral Tablet) B 3 PA A1

AntidepressantsB1

Antidepressants, OtherC1

Bupropi

on HCl

SR Bupropion HCl SR (Oral Tablet Extended Release 12

Hour)G 2 ¨

C1

Bup

ropi

on HCl

XL Bupropion HCl XL (150MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release

24 Hour)

G 2 ¨

C1

Bup

ropion

HCl

Bupropion HCl (Oral Tablet Immediate Release) G 2 ¨C1

Map

rotiline

HCl

Maprotiline HCl (Oral Tablet) G 4

C1

Mirtaza

pine

Mirtazapine (Oral Tablet) G 2 ¨C1

Mirtaza

pine

ODT Mirtazapine ODT (Oral Tablet Dispersible) G 2 ¨B1

Monoamine Oxidase InhibitorsC1

Ems

am

Emsam (Transdermal Patch 24 Hour) B 5 DL; QL C1

Marplan

Marplan (Oral Tablet) B 4

C1

Phenelzi

ne Sulf

ate Phenelzine Sulfate (Oral Tablet) G 3

C1

Tran

ylcy

promin

e Sulf

ate Tranylcypromine Sulfate (Oral Tablet) G 4

B1

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine

Reuptake Inhibitors)C1

Cital

opram

Hydrobr

omide Citalopram Hydrobromide (Oral Solution) G 3

C1

Citalopra

m Hyd

robr

omide Citalopram Hydrobromide (Oral Tablet) G 1 ¨C1

Des

venl

afaxine

Succina

te

ER Desvenlafaxine Succinate ER (Oral Tablet Extended

Release 24 Hour) (Generic Pristiq)G 3 QL

C1

Esci

talopra

m

Oxalate Escitalopram Oxalate (Oral Solution) G 2 ¨C1

Esci

talopra

m Oxal

ate Escitalopram Oxalate (Oral Tablet) G 1 ¨C1

Fetzima

Fetzima (Oral Capsule Extended Release 24 Hour) B 4 ST; QL C1

Fetzima

Titration

Fetzima Titration (Oral Capsule ER 24 Hour Therapy

Pack)B 4 ST

C1

Fluo

xeti

ne HCl

Fluoxetine HCl (10MG Oral Capsule Immediate Release,

20MG Oral Capsule Immediate Release, 40MG Oral

Capsule Immediate Release)

G 2 ¨

C1

Fluo

xetine

HCl

Fluoxetine HCl (90MG Oral Capsule Delayed Release) G 4

C1

Fluoxeti

ne

HCl

Fluoxetine HCl (20MG/5ML Oral Solution) G 2 ¨C1

Fluvoxa

mine

Mal

eate Fluvoxamine Maleate (Oral Tablet) G 3

C1

Nef

azo

done

HCl Nefazodone HCl (Oral Tablet) G 4

C1

Paro

xetine

HCl

Paroxetine HCl (Oral Tablet Immediate Release) G 2 ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Paxil

Paxil (Oral Suspension) B 4

C1

Sertralin

e HCl

Sertraline HCl (Oral Concentrate) G 4

C1

Sert

ralin

e HCl

Sertraline HCl (Oral Tablet) G 1 ¨C1

Traz

odone

HCl

Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet,


C1

Trazodo

ne

HCl

Trazodone HCl (300MG Oral Tablet) G 2 ¨C1

Trintellix

Trintellix (Oral Tablet) B 4 QL C1

Venl

afaxi

ne HCl

ER Venlafaxine HCl ER (Oral Capsule Extended Release 24 Hour)

G 2 ¨C1

Venl

afaxine

HCl

Venlafaxine HCl (Oral Tablet Immediate Release) G 3

C1

Viibr

yd

Viibryd (Oral Tablet) B 4 QL C1

Viibryd

Start

er Pac

k Viibryd Starter Pack (Oral Kit) B 4 QL B1

TricyclicsC1

Amit

riptyline

HCl

Amitriptyline HCl (Oral Tablet) G 4

C1

Am

oxapine

Amoxapine (Oral Tablet) G 3

C1

Clomipr

ami

ne HCl Clomipramine HCl (Oral Capsule) G 4

C1

Desipra

mine

HCl Desipramine HCl (Oral Tablet) G 3

C1

Dox

epin

HCl

Doxepin HCl (Oral Capsule) G 3

C1

Dox

epin HCl

Doxepin HCl (Oral Concentrate) G 3

C1

Imip

ramine

HCl

Imipramine HCl (Oral Tablet) G 4

C1

Imiprami

ne Pam

oate Imipramine Pamoate (Oral Capsule) G 4

C1

Nort

ripty

line HCl

Nortriptyline HCl (Oral Capsule) G 2 ¨C1

Nort

riptyline

HCl

Nortriptyline HCl (Oral Solution) G 2 ¨C1

Prot

riptyline

HCl

Protriptyline HCl (Oral Tablet) G 4

C1

Trimipra

min

e Mal

eate Trimipramine Maleate (Oral Capsule) G 4

A1

AntiemeticsB1

Antiemetics, OtherC1

Co

mpro

Compro (Rectal Suppository) G 4

C1

Meclizin

e

HCl

Meclizine HCl (Oral Tablet) G 2 ¨C1

Metoclo

pramid

e

HCl Metoclopramide HCl (5MG/5ML Oral Solution) G 2 ¨C1

Met

oclo

pramid

e HCl Metoclopramide HCl (Oral Tablet) G 1 ¨C1

Per

phenazi

ne

Perphenazine (Oral Tablet) G 4

C1

Proc

hlorpera

zine Mal

eate Prochlorperazine Maleate (Oral Tablet) G 2 ¨C1

Prochlor

pera

zine

Prochlorperazine (Rectal Suppository) G 4




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Promet

hazi

ne HCl Promethazine HCl (Oral Syrup) G 3

C1

Promet

hazine

HCl Promethazine HCl (Oral Tablet) G 3

C1

Pro

met

hazine

HCl Promethazine HCl (Rectal Suppository) G 4

C1

Pro

metheg

an

Promethegan (25MG Rectal Suppository) G 4

C1

Scopola

min

e

Scopolamine (Transdermal Patch 72 Hour) G 4

C1

Transder

m-Sco

p Transderm-Scop (1.5MG) (Transdermal Patch 72

Hour)B 4

B1

Emetogenic Therapy AdjunctsC1

Apr

epitant

Aprepitant (Oral Therapy Pack, Oral Capsule) G 4 PA C1

Dro

nabinol

Dronabinol (Oral Capsule) G 4 PA C1

Granise

tron

HCl

Granisetron HCl (Oral Tablet) G 4 B/D, PA; QL C1

Ondans

etron

HCl Ondansetron HCl (Oral Solution) G 4 B/D, PA C1

Ond

ansetro

n

HCl Ondansetron HCl (Oral Tablet) G 2 B/D, PA ¨C1

Ond

ansetro

n ODT Ondansetron ODT (Oral Tablet Dispersible) G 2 B/D, PA ¨C1

Sancus

o

Sancuso (Transdermal Patch) B 5 DL; QL A1

AntifungalsB1

AntifungalsC1

Abel

cet

Abelcet (Intravenous Suspension) B 4 B/D, PA C1

Am

Bisome

AmBisome (Intravenous Suspension Reconstituted) B 5 B/D, PA; DL C1

Amphot

ericin B

Amphotericin B (Intravenous Solution Reconstituted) G 4 B/D, PA C1

Clot

rima

zole

Clotrimazole (Mouth/Throat Troche) G 2 ¨C1

Fluc

onazole

in

Sodium

Chloride Fluconazole in Sodium Chloride (Intravenous Solution) G 4

C1

Fluc

onazole

Fluconazole (Oral Suspension Reconstituted) G 2 ¨C1

Flucona

zole

Fluconazole (Oral Tablet) G 2 ¨C1

Flucytosi

ne

Flucytosine (Oral Capsule) G 5 DL C1

Gris

eofu

lvin Micr

osize Griseofulvin Microsize (Oral Suspension) G 4

C1

Gris

eofulvin

Microsiz

e Griseofulvin Microsize (Oral Tablet) G 4

C1

Griseofu

lvin

Ultramicr

osize Griseofulvin Ultramicrosize (Oral Tablet) G 4

C1

Itracona

zole

Itraconazole (Oral Capsule) G 4 PA; QL C1

Itrac

ona

zole

Itraconazole (Oral Solution) G 5 PA; DL C1

Ket

oconaz

ole

Ketoconazole (Oral Tablet) G 2 ¨C1

Mic

afungin

Sodium Micafungin Sodium (Intravenous Solution Reconstituted) G 4

C1

Micona

zole

3

Miconazole 3 (Vaginal Suppository) G 3

C1

Noxafil

Noxafil (Oral Suspension) B 5 DL; QL C1

Nyst

atin

Nystatin (Mouth/Throat Suspension) G 2 ¨C1

Nyst

atin

Nystatin (Oral Tablet) G 2 ¨C1

Posaco

naz

ole

Posaconazole (Oral Tablet Delayed Release) G 5 PA; DL; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Terbinafi

ne

HCl

Terbinafine HCl (Oral Tablet) G 2 ¨C1

Tercona

zole

Terconazole (Vaginal Cream) G 3

C1

Terc

ona

zole

Terconazole (Vaginal Suppository) G 3

C1

Vori

conazol

e

Voriconazole (Intravenous Solution Reconstituted) G 5 DL C1

Voricon

azol

e

Voriconazole (Oral Suspension Reconstituted) G 5 DL C1

Voricon

azole

Voriconazole (Oral Tablet) G 4

A1

Antigout AgentsB1

Antigout AgentsC1

Allo

purinol

Allopurinol (Oral Tablet) G 1 ¨C1

Colchicin

e

Colchicine (0.6MG Oral Capsule) (Brand Equivalent

Mitigare)B 3 QL

C1

Colchicin

e

Colchicine (0.6MG Oral Tablet) (Generic Colcrys) G 3 QL C1

Feb

uxostat

Febuxostat (Oral Tablet) G 3 ST C1

Pro

benecid

Probenecid (Oral Tablet) G 2 ¨C1

Proben

ecid

-Colc

hicine Probenecid-Colchicine (Oral Tablet) G 2 ¨

A1

Antimigraine AgentsB1

AcuteC1

Nar

atriptan

HCl

Naratriptan HCl (Oral Tablet) G 3 QL C1

Riza

triptan

Benzoat

e Rizatriptan Benzoate (Oral Tablet) G 3 QL C1

Rizatript

an Ben

zoat

e ODT Rizatriptan Benzoate ODT (Oral Tablet Dispersible) G 3 QL C1

Sum

atrip

tan

Sumatriptan (Nasal Solution) G 4 QL C1

Sum

atriptan

Suc

cinate Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral

Tablet, 50MG Oral Tablet)G 2 QL ¨

C1

Sum

atriptan

Succina

te

Refill Sumatriptan Succinate Refill (Subcutaneous Solution

Cartridge)G 4 QL

C1

Sumatrip

tan

Succina

te Sumatriptan Succinate (6MG/0.5ML Subcutaneous

Solution)G 4 QL

C1

Sumatrip

tan Suc

cina

te Sumatriptan Succinate (4MG/0.5ML Subcutaneous

Solution Auto-Injector, 6MG/0.5ML Subcutaneous

Solution Auto-Injector)

G 4 QL

C1

Sum

atrip

tan Suc

cinate Sumatriptan Succinate (6MG/0.5ML Subcutaneous

Solution Prefilled Syringe)G 4 QL

B1

Ergot AlkaloidsC1

Dihydroe

rgot

amine

Mesylate Dihydroergotamine Mesylate (Nasal Solution) G 5 PA; DL; QL C1

Ergota

mine-

Caff

eine Ergotamine-Caffeine (Oral Tablet) G 3




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Migergo

t

Migergot (Rectal Suppository) G 5 DL B1

ProphylacticC1

Aim

ovig

Aimovig (Subcutaneous Solution Auto-Injector) B 4 PA; QL C1

Emg

ality

Emgality (300MG Dose) (100MG/ML Subcutaneous

Solution Prefilled Syringe)B 4 PA; QL

C1

Emgality

Emgality (Subcutaneous Solution Auto-Injector) B 4 PA; QL C1

Emgality

Emgality (120MG/ML Subcutaneous Solution

Prefilled Syringe)B 4 PA; QL

C1

Tim

olol

Maleate

Timolol Maleate (Oral Tablet) G 3

A1

Antimyasthenic AgentsB1

ParasympathomimeticsC1

Guanidi

ne

HCl

Guanidine HCl (Oral Tablet) B 3

C1

Pyridost

igmine

Bromid

e

ER Pyridostigmine Bromide ER (Oral Tablet Extended Release)

G 4

C1

Pyri

dostigmi

ne

Bromid

e Pyridostigmine Bromide (Oral Solution) G 5 DL C1

Pyri

dostigmi

ne Bro

mid

e Pyridostigmine Bromide (60MG Oral Tablet Immediate Release)

G 3

A1

AntimycobacterialsB1

Antimycobacterials, OtherC1

Dap

son

e

Dapsone (Oral Tablet) G 3

C1

Rifa

butin

Rifabutin (Oral Capsule) G 4

B1

AntitubercularsC1

Ethambu

tol HCl

Ethambutol HCl (Oral Tablet) G 3

C1

Ison

iazid

Isoniazid (Oral Syrup) G 4

C1

Ison

iazid

Isoniazid (Oral Tablet) G 2 ¨C1

Pas

er

Paser (Oral Packet) G 4

C1

Priftin

Priftin (Oral Tablet) B 4

C1

Pyrazina

mide

Pyrazinamide (Oral Tablet) G 4

C1

Rifa

mpi

n

Rifampin (600MG Intravenous Solution Reconstituted) G 4

C1

Rifa

mpin

Rifampin (150MG Oral Capsule, 300MG Oral Capsule) G 3

C1

Sirturo

Sirturo (100MG Oral Tablet) B 5 PA; LA; DL C1

Trecator

Trecator (Oral Tablet) B 4

A1

AntineoplasticsB1

Alkylating AgentsC1

Cycl

ophosp

hamide Cyclophosphamide (25MG Oral Capsule) G 3 B/D, PA C1

Cycloph

osp

hamide Cyclophosphamide (50MG Oral Capsule) G 4 B/D, PA C1

Leukera

n

Leukeran (Oral Tablet) B 5 DL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Matulan

e

Matulane (Oral Capsule) B 5 LA; DL C1

Valchlor

Valchlor (External Gel) B 5 PA; LA; DL; QL B1

AntiandrogensC1

Abir

aterone

Acetate Abiraterone Acetate (Oral Tablet) G 5 PA; DL; QL C1

Bicaluta

mid

e

Bicalutamide (Oral Tablet) G 2 ¨C1

Erleada

Erleada (Oral Tablet) B 5 PA; DL; QL C1

Flut

ami

de

Flutamide (Oral Capsule) G 3

C1

Nilut

amide

Nilutamide (Oral Tablet) G 5 DL C1

Nub

eqa

Nubeqa (Oral Tablet) B 5 PA; LA; DL; QL C1

Xtandi

Xtandi (Oral Capsule) B 5 PA; LA; DL; QL B1

Antiangiogenic AgentsC1

Pom

alyst

Pomalyst (Oral Capsule) B 5 PA; DL; QL C1

Qinl

ock

Qinlock (Oral Tablet) B 5 PA; DL; QL C1

Revlimid

Revlimid (Oral Capsule) B 5 PA; LA; DL; QL C1

Tabrecta

Tabrecta (Oral Tablet) B 5 PA; DL; QL C1

Thal

omi

d

Thalomid (Oral Capsule) B 5 PA; DL; QL B1

Antiestrogens/ModifiersC1

Emc

yt

Emcyt (Oral Capsule) B 5 DL C1

Soltamo

x

Soltamox (Oral Solution) B 5 DL C1

Tam

oxif

en Citra

te Tamoxifen Citrate (Oral Tablet) G 2 ¨C1

Tore

mifene

Citra

te Toremifene Citrate (Oral Tablet) G 5 DL B1

AntimetabolitesC1

Droxia

Droxia (Oral Capsule) B 4

C1

Hydroxy

urea

Hydroxyurea (Oral Capsule) G 2 ¨C1

Mer

capt

opurine

Mercaptopurine (Oral Tablet) G 3

C1

Puri

xan

Purixan (Oral Suspension) B 5 PA; DL C1

Tabloid

Tabloid (Oral Tablet) B 4 PA B1

Antineoplastics, OtherC1

IDHI

FA

IDHIFA (Oral Tablet) B 5 PA; LA; DL; QL C1

Lon

surf

Lonsurf (Oral Tablet) B 5 PA; LA; DL; QL C1

Ninl

aro

Ninlaro (Oral Capsule) B 5 PA; DL; QL C1

Pemazyr

e

Pemazyre (Oral Tablet) B 5 PA; DL; QL C1

Retevm

o

Retevmo (Oral Capsule) B 5 PA; DL; QL C1

Synr

ibo

Synribo (Subcutaneous Solution Reconstituted) B 5 PA; DL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Tazverik

Tazverik (Oral Tablet) B 5 PA; LA; DL; QL C1

Tukysa

Tukysa (Oral Tablet) B 5 PA; DL; QL C1

Xpo

vio

Xpovio (100MG Once Weekly) (Oral Tablet Therapy

Pack)B 5 PA; LA; DL; QL

C1

Xpo

vio



C1

Xpovio



C1

Xpovio

Xpovio (80MG Twice Weekly) (Oral Tablet Therapy


C1

Zoli

nza

Zolinza (Oral Capsule) B 5 PA; DL B1

Aromatase Inhibitors, 3rd GenerationC1

Ana

strozole

Anastrozole (Oral Tablet) G 1 ¨C1

Exemes

tane

Exemestane (Oral Tablet) G 4

C1

Letrozol

e

Letrozole (Oral Tablet) G 2 ¨B1

Molecular Target InhibitorsC1

Afini

tor Disp

erz

Afinitor Disperz (Oral Tablet Soluble) B 5 PA; DL C1

Afinitor

Afinitor (10MG Oral Tablet) B 5 PA; DL C1

Alecens

a

Alecensa (Oral Capsule) B 5 PA; LA; DL; QL C1

Alun

brig

Alunbrig (Oral Tablet) B 5 PA; LA; DL; QL C1

Alun

brig

Alunbrig (Oral Tablet Therapy Pack) B 5 PA; LA; DL; QL C1

Ayv

akit

Ayvakit (Oral Tablet) B 5 PA; LA; DL; QL C1

Balversa

Balversa (Oral Tablet) B 5 PA; LA; DL; QL C1

Bos

ulif

Bosulif (Oral Tablet) B 5 PA; DL; QL C1

Braf

tovi

Braftovi (Oral Capsule) B 5 PA; DL C1

Bruk

insa

Brukinsa (Oral Capsule) B 5 PA; LA; DL; QL C1

Cabome

tyx

Cabometyx (Oral Tablet) B 5 PA; LA; DL; QL C1

Calquen

ce

Calquence (Oral Capsule) B 5 PA; DL; QL C1

Cap

rels

a

Caprelsa (Oral Tablet) B 5 PA; LA; DL C1

Co

metriq

Cometriq (100MG Daily Dose) (Oral Kit) B 5 PA; LA; DL C1

Cometr

iq


Cometr

iq


Cop

iktra

Copiktra (Oral Capsule) B 5 PA; DL; QL C1

Cot

ellic

Cotellic (Oral Tablet) B 5 PA; LA; DL; QL C1

Dau

rismo

Daurismo (Oral Tablet) B 5 PA; LA; DL; QL C1

Erivedg

e

Erivedge (Oral Capsule) B 5 PA; LA; DL; QL C1

Erlotinib

HCl

Erlotinib HCl (Oral Tablet) G 5 PA; DL; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Everolim

us

Everolimus (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG

Oral Tablet)G 5 PA; DL

C1

Farydak

Farydak (Oral Capsule) B 5 PA; DL C1

Gilot

rif

Gilotrif (Oral Tablet) B 5 PA; LA; DL C1

Ibra

nce

Ibrance (Oral Capsule) B 5 PA; LA; DL; QL C1

Ibrance

Ibrance (Oral Tablet) B 5 PA; LA; DL; QL C1

Iclusig

Iclusig (Oral Tablet) B 5 PA; LA; DL; QL C1

Imat

inib

Mesylate

Imatinib Mesylate (Oral Tablet) G 5 PA; DL; QL C1

Imbr

uvica

Imbruvica (Oral Capsule) B 5 PA; LA; DL; QL C1

Imbr

uvica

Imbruvica (Oral Tablet) B 5 PA; DL; QL C1

Inlyta

Inlyta (Oral Tablet) B 5 PA; LA; DL; QL C1

Inrebic

Inrebic (Oral Capsule) B 5 PA; DL; QL C1

Ires

sa

Iressa (Oral Tablet) B 5 PA; LA; DL; QL C1

Jaka

fi

Jakafi (Oral Tablet) B 5 PA; LA; DL; QL C1

Kisqali

Kisqali (200MG Dose) (Oral Tablet) B 5 PA; DL; QL C1

Kisqali


Kisq

ali


Kisq

ali Fem

ara

Kisqali Femara (400MG Dose) (Oral Tablet Therapy

Pack)B 5 PA; DL; QL

C1

Kisq

ali Fem

ara


Pack)B 5 PA; DL; QL

C1

Kisqali

Femara


Pack)B 5 PA; DL; QL

C1

Kos

elug

o

Koselugo (Oral Capsule) B 5 PA; DL; QL C1

Len

vima

10M

G Dail

y Dos

e Lenvima 10MG Daily Dose (Oral Capsule Therapy

Pack)B 5 PA; LA; DL

C1

Len

vima

12MG

Dail

y Dos


Pack)B 5 PA; LA; DL

C1

Lenvima

14MG

Daily

Dose Lenvima 14MG Daily Dose (Oral Capsule Therapy

Pack)B 5 PA; LA; DL

C1

Lenvima

18M

G

Daily


Pack)B 5 PA; LA; DL

C1

Len

vima

20M

G Dail

y Dos


Pack)B 5 PA; LA; DL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lenvima

24MG

Daily


Pack)B 5 PA; LA; DL

C1

Lenvima

4M

G Dail

y


Pack)B 5 PA; LA; DL

C1

Len

vima

8M

G Dail

y Dos


Pack)B 5 PA; LA; DL

C1

Lorb

rena

Lorbrena (Oral Tablet) B 5 PA; LA; DL; QL C1

Lynparz

a

Lynparza (Oral Tablet) B 5 PA; LA; DL; QL C1

Mekinist

Mekinist (Oral Tablet) B 5 PA; LA; DL C1

Mek

tovi

Mektovi (Oral Tablet) B 5 PA; DL C1

Nerl

ynx

Nerlynx (Oral Tablet) B 5 PA; LA; DL; QL C1

Nex

avar

Nexavar (Oral Tablet) B 5 PA; LA; DL C1

Odomzo

Odomzo (Oral Capsule) B 5 PA; LA; DL; QL C1

Piqray

Piqray (200MG Daily Dose) (Oral Tablet Therapy

Pack)B 5 PA; DL; QL

C1

Piqr

ay


Pack)B 5 PA; DL; QL

C1

Piqr

ay


Pack)B 5 PA; DL; QL

C1

Rozlytre

k

Rozlytrek (Oral Capsule) B 5 PA; DL; QL C1

Rubraca

Rubraca (Oral Tablet) B 5 PA; LA; DL; QL C1

Ryd

apt

Rydapt (Oral Capsule) B 5 PA; DL; QL C1

Spry

cel

Sprycel (Oral Tablet) B 5 PA; DL; QL C1

Stiv

arga

Stivarga (Oral Tablet) B 5 PA; LA; DL; QL C1

Sutent

Sutent (Oral Capsule) B 5 PA; DL; QL C1

Tafi

nlar

Tafinlar (Oral Capsule) B 5 PA; LA; DL C1

Tagr

isso

Tagrisso (Oral Tablet) B 5 PA; LA; DL; QL C1

Talz

enna

Talzenna (Oral Capsule) B 5 PA; LA; DL; QL C1

Tasigna

Tasigna (Oral Capsule) B 5 PA; DL; QL C1

Tibsovo

Tibsovo (Oral Tablet) B 5 PA; DL; QL C1

Tura

lio

Turalio (Oral Capsule) B 5 PA; LA; DL; QL C1

Tyk

erb

Tykerb (Oral Tablet) B 5 PA; LA; DL C1

Venclext

a

Venclexta (100MG Oral Tablet, 50MG Oral Tablet) B 5 PA; LA; DL; QL C1

Venclext

a

Venclexta (10MG Oral Tablet) B 3 PA; LA; QL C1

Ven

clext

a Start

ing Pac

k Venclexta Starting Pack (Oral Tablet Therapy Pack) B 5 PA; LA; DL C1

Verz

enio

Verzenio (Oral Tablet) B 5 PA; LA; DL; QL C1

Vitra

kvi

Vitrakvi (Oral Capsule) B 5 PA; LA; DL; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Vitrakvi

Vitrakvi (Oral Solution) B 5 PA; LA; DL; QL C1

Vizimpr

o

Vizimpro (Oral Tablet) B 5 PA; LA; DL; QL C1

Votri

ent

Votrient (Oral Tablet) B 5 PA; LA; DL; QL C1

Xalk

ori

Xalkori (Oral Capsule) B 5 PA; LA; DL C1

Xospata

Xospata (Oral Tablet) B 5 PA; DL; QL C1

Zejula

Zejula (Oral Capsule) B 5 PA; LA; DL; QL C1

Zelb

oraf

Zelboraf (Oral Tablet) B 5 PA; LA; DL; QL C1

Zyd

elig

Zydelig (Oral Tablet) B 5 PA; LA; DL; QL C1

Zyk

adia

Zykadia (Oral Tablet) B 5 PA; DL; QL B1

RetinoidsC1

Bexarot

ene

Bexarotene (Oral Capsule) G 5 PA; DL C1

Targ

retin

Targretin (External Gel) B 5 PA; DL; QL C1

Treti

noin

Tretinoin (Oral Capsule) G 5 DL B1

Treatment AdjunctsC1

Leucov

orin Calc

ium Leucovorin Calcium (10MG Oral Tablet, 15MG Oral

Tablet, 5MG Oral Tablet)G 3

C1

Leu

cov

orin Calc

ium Leucovorin Calcium (25MG Oral Tablet) G 4

C1

Mes

nex

Mesnex (Oral Tablet) B 5 DL A1

AntiparasiticsB1

AnthelminticsC1

Albe

nda

zole

Albendazole (Oral Tablet) G 5 DL; QL C1

Iver

mectin

Ivermectin (Oral Tablet) G 3

C1

Praz

iquantel

Praziquantel (Oral Tablet) G 4

B1

AntiprotozoalsC1

Alinia

Alinia (Oral Suspension Reconstituted) B 5 DL C1

Alini

a

Alinia (Oral Tablet) B 5 DL C1

Atov

aquone

Atovaquone (Oral Suspension) G 5 DL C1

Atovaqu

one-

Progua

nil HCl Atovaquone-Proguanil HCl (Oral Tablet) G 3

C1

Benznid

azole

Benznidazole (Oral Tablet) B 4

C1

Chlo

roqu

ine Pho

sphate Chloroquine Phosphate (Oral Tablet) G 2 QL ¨C1

Coa

rtem

Coartem (Oral Tablet) B 4

C1

DAR

APRIM

DARAPRIM (Oral Tablet) B 5 DL C1

Hydroxy

chlo

roquine

Sulfate Hydroxychloroquine Sulfate (Oral Tablet) G 2 QL ¨C1

Mefloqui

ne HCl

Mefloquine HCl (Oral Tablet) G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pentami

dine

Iset

hionate Pentamidine Isethionate (Inhalation Solution

Reconstituted)G 4 B/D, PA; QL

C1

Pentami

dine

Isethion

ate Pentamidine Isethionate (Injection Solution

Reconstituted)G 4

C1

Prim

aqui

ne Pho

sphate Primaquine Phosphate (Oral Tablet) G 4

C1

Pyri

metham

ine

Pyrimethamine (Oral Tablet) G 5 DL C1

Quinine

Sulf

ate

Quinine Sulfate (Oral Capsule) G 4 PA A1

Antiparkinson AgentsB1

AnticholinergicsC1

Ben

ztropine

Mesylate Benztropine Mesylate (Oral Tablet) G 2 ¨C1

Trih

exyphe

nidyl HCl Trihexyphenidyl HCl (Oral Solution) G 2 ¨C1

Trihexy

phe

nidyl HCl Trihexyphenidyl HCl (Oral Tablet) G 2 ¨

B1

Antiparkinson Agents, OtherC1

Ama

ntadine

HCl

Amantadine HCl (Oral Capsule) G 3

C1

Ama

ntadine

HCl

Amantadine HCl (Oral Syrup) G 2 ¨C1

Amantad

ine

HCl

Amantadine HCl (Oral Tablet) G 3

C1

Carbido

pa-Lev

odo

pa-Enta

capone Carbidopa-Levodopa-Entacapone (Oral Tablet) G 4

C1

Enta

cap

one

Entacapone (Oral Tablet) G 4

C1

Tolc

apone

Tolcapone (Oral Tablet) G 5 DL; QL B1

Dopamine AgonistsC1

Apokyn

Apokyn (Subcutaneous Solution Cartridge) B 5 PA; LA; DL; QL C1

Bro

moc

riptine

Mesylate Bromocriptine Mesylate (Oral Capsule) G 3

C1

Bro

mocripti

ne

Mesylate Bromocriptine Mesylate (Oral Tablet) G 3

C1

Neu

pro

Neupro (Transdermal Patch 24 Hour) B 4

C1

Pramip

exol

e Dihy

drochlori

de Pramipexole Dihydrochloride (Oral Tablet Immediate

Release)G 2 ¨

C1

Ropiniro

le HCl

Ropinirole HCl (Oral Tablet Immediate Release) G 2 ¨B1

Dopamine Precursors and/or L-Amino Acid Decarboxylase InhibitorsC1

Car

bidopa

Carbidopa (Oral Tablet) G 4

C1

Carbido

pa-

Levodo

pa ER Carbidopa-Levodopa ER (Oral Tablet Extended Release) G 1 ¨C1

Carbido

pa-Lev

odo

pa Carbidopa-Levodopa (Oral Tablet Immediate Release) G 1 ¨C1

Car

bido

pa-Lev

odopa

ODT Carbidopa-Levodopa ODT (Oral Tablet Dispersible) G 2 ¨C1

Ryta

ry

Rytary (Oral Capsule Extended Release) B 4 ST B1

Monoamine Oxidase B (MAO-B) InhibitorsC1

Rasagili

ne

Mesylate Rasagiline Mesylate (Oral Tablet) G 4

C1

Selegilin

e HCl

Selegiline HCl (Oral Capsule) G 3

C1

Sele

giline

HCl

Selegiline HCl (Oral Tablet) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Zelapar

ODT

Zelapar ODT (Oral Tablet Dispersible) B 5 DL A1

AntipsychoticsB1

1st Generation/TypicalC1

Chlo

rpromazi

ne HCl Chlorpromazine HCl (Oral Tablet) G 4

C1

Fluphen

azin

e Dec

anoate Fluphenazine Decanoate (Injection Solution) G 4

C1

Fluphen

azine

HCl Fluphenazine HCl (2.5MG/ML Injection Solution) G 4

C1

Flup

hen

azine

HCl Fluphenazine HCl (5MG/ML Oral Concentrate) G 3

C1

Flup

henazin

e

HCl Fluphenazine HCl (2.5MG/5ML Oral Elixir) G 4

C1

Flup

henazin

e HCl Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet,

2.5MG Oral Tablet, 5MG Oral Tablet)G 2 ¨

C1

Haloperi

dol

Decano

ate Haloperidol Decanoate (Intramuscular Solution) G 4

C1

Haloperi

dol Lact

ate Haloperidol Lactate (Injection Solution) G 4

C1

Halo

peridol

Lact

ate Haloperidol Lactate (Oral Concentrate) G 2 ¨C1

Halo

peridol

Haloperidol (Oral Tablet) G 2 ¨C1

Loxapin

e

Succina

te Loxapine Succinate (Oral Capsule) G 2 ¨C1

Molindo

ne HCl

Molindone HCl (Oral Tablet) G 4

C1

Pim

ozid

e

Pimozide (Oral Tablet) G 4

C1

Thio

ridazine

HCl

Thioridazine HCl (Oral Tablet) G 3

C1

Thio

thixene

Thiothixene (Oral Capsule) G 3

C1

Trifluop

erazine

HCl Trifluoperazine HCl (Oral Tablet) G 3

B1

2nd Generation/AtypicalC1

Abili

fy Mai

nten

a Abilify Maintena (Intramuscular Prefilled Syringe) B 5 DL C1

Abili

fy Mai

ntena Abilify Maintena (Intramuscular Suspension

Reconstituted ER)B 5 DL

C1

Aripipraz

ole

Aripiprazole (1MG/ML Oral Solution) G 4 QL C1

Aripipraz

ole

Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet,

20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)

G 3 QL

C1

Aripi

praz

ole ODT

Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG

Oral Tablet Dispersible)G 5 DL; QL

C1

Arist

ada Initi

o

Aristada Initio (Intramuscular Prefilled Syringe) B 5 DL C1

Aristada

Aristada (Intramuscular Prefilled Syringe) B 5 DL C1

Caplyta

Caplyta (Oral Capsule) B 5 ST; DL; QL C1

Fan

apt

Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 4MG

Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet)B 5 ST; DL; QL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Fanapt

Fanapt (1MG Oral Tablet, 2MG Oral Tablet) B 4 ST; QL C1

Fanapt

Titration

Pack Fanapt Titration Pack (Oral Tablet) B 4 ST C1

Geo

don

Geodon (Intramuscular Solution Reconstituted) B 4

C1

Inve

ga Sust

enna Invega Sustenna (117MG/0.75ML Intramuscular

Suspension Prefilled Syringe, 156MG/ML

Intramuscular Suspension Prefilled Syringe, 234MG/

1.5ML Intramuscular Suspension Prefilled Syringe,

78MG/0.5ML Intramuscular Suspension Prefilled

Syringe)

B 5 DL

C1

Invega

Sust

enna Invega Sustenna (39MG/0.25ML Intramuscular

Suspension Prefilled Syringe)B 4

C1

Invega

Trinza

Invega Trinza (Intramuscular Suspension Prefilled

Syringe)B 5 DL

C1

Latu

da

Latuda (Oral Tablet) B 5 DL; QL C1

Nup

lazid

Nuplazid (Oral Capsule) B 5 PA; DL; QL C1

Nup

lazid

Nuplazid (Oral Tablet) B 5 PA; DL; QL C1

Olanzapi

ne

Olanzapine (10MG Intramuscular Solution

Reconstituted)G 4

C1

Olanzapi

ne

Olanzapine (10MG Oral Tablet, 15MG Oral Tablet,

2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)

G 2 QL ¨

C1

Olan

zapine

ODT

Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG

Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)

G 4 QL

C1

Pali

peridon

e ER Paliperidone ER (Oral Tablet Extended Release 24 Hour) G 4 QL C1

Perseris

Perseris (Subcutaneous Prefilled Syringe) B 5 DL C1

Quetiapi

ne Fum

arat

e ER Quetiapine Fumarate ER (Oral Tablet Extended Release

24 Hour)G 3 QL

C1

Que

tiapi

ne Fum

arate Quetiapine Fumarate (Oral Tablet Immediate Release) G 2 QL ¨C1

Rex

ulti

Rexulti (Oral Tablet) B 5 DL; QL C1

Risp

erdal

Consta Risperdal Consta (12.5MG Intramuscular Suspension

Reconstituted ER, 25MG Intramuscular Suspension

Reconstituted ER)

B 4

C1

Risperda

l Con

sta Risperdal Consta (37.5MG Intramuscular Suspension

Reconstituted ER, 50MG Intramuscular Suspension

Reconstituted ER)

B 5 DL

C1

Risp

erid

one

Risperidone (1MG/ML Oral Solution) G 4

C1

Risp

eridone

Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet,

1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet,

4MG Oral Tablet)

G 2 ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Risperid

one

ODT

Risperidone ODT (0.25MG Oral Tablet Dispersible,

0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible, 3MG Oral

Tablet Dispersible, 4MG Oral Tablet Dispersible)

G 4

C1

Saphris

Saphris (Tablet Sublingual) B 5 DL; QL C1

Sec

uad

o

Secuado (Transdermal Patch 24 Hour) B 5 PA; DL; QL C1

Vray

lar

Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule,

4.5MG Oral Capsule, 6MG Oral Capsule)B 5 ST; DL; QL

C1

Vraylar

Vraylar (Oral Capsule Therapy Pack) B 4 ST C1

Ziprasid

one HCl

Ziprasidone HCl (Oral Capsule) G 3 QL C1

Zipr

asid

one Mes

ylate Ziprasidone Mesylate (Intramuscular Solution Reconstituted)

G 4

C1

Zypr

exa Relp

revv

Zyprexa Relprevv (210MG Intramuscular Suspension

Reconstituted)B 4

B1

Treatment-ResistantC1

Clozapin

e

Clozapine (100MG Oral Tablet, 200MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

G 3

C1

Clozapin

e ODT

Clozapine ODT (100MG Oral Tablet Dispersible, 12.5MG Oral Tablet Dispersible, 150MG Oral Tablet Dispersible,

200MG Oral Tablet Dispersible, 25MG Oral Tablet Dispersible)

G 4 QL

C1

Vers

acloz

Versacloz (Oral Suspension) B 5 DL A1

Antispasticity AgentsB1

Antispasticity AgentsC1

Baclofen

Baclofen (Oral Tablet) G 2 ¨C1

Dant

role

ne Sodi

um Dantrolene Sodium (Oral Capsule) G 4

C1

Tiza

nidine

HCl

Tizanidine HCl (Oral Tablet) G 2 ¨A1

AntiviralsB1

Anti-cytomegalovirus (CMV) AgentsC1

Valg

anci

clovir

HCl Valganciclovir HCl (50MG/ML Oral Solution

Reconstituted)G 5 DL; QL

C1

Valg

anciclovi

r

HCl Valganciclovir HCl (450MG Oral Tablet) G 3 QL C1

Zirg

an

Zirgan (Ophthalmic Gel) B 4

B1

Anti-hepatitis B (HBV) AgentsC1

Adefovir

Dipi

voxil Adefovir Dipivoxil (Oral Tablet) G 5 DL C1

Bara

clud

e

Baraclude (Oral Solution) B 5 DL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Entecavir

Entecavir (Oral Tablet) G 4

C1

Epivir

HBV

Epivir HBV (Oral Solution) B 4

C1

Lam

ivudi

ne

Lamivudine (100MG Oral Tablet) G 3

C1

Vem

lidy

Vemlidy (Oral Tablet) B 5 DL; QL B1

Anti-hepatitis C (HCV) AgentsC1

Epclusa

Epclusa (Oral Tablet) B 5 PA; DL; QL C1

Mav

yret

Mavyret (Oral Tablet) B 5 PA; DL; QL C1

Riba

virin

Ribavirin (Oral Tablet) G 3

C1

Sof

osbuvir-

Velpatas

vir Sofosbuvir-Velpatasvir (Oral Tablet) G 5 PA; DL; QL C1

Sovaldi

Sovaldi (Oral Packet) B 5 PA; DL; QL C1

Sovaldi

Sovaldi (400MG Oral Tablet) B 5 PA; DL; QL C1

Vos

evi

Vosevi (Oral Tablet) B 5 PA; DL; QL B1

Antiherpetic AgentsC1

Acyclovi

r

Acyclovir (External Ointment) G 4 QL C1

Acyclovi

r

Acyclovir (Oral Capsule) G 2 ¨C1

Acy

clovi

r

Acyclovir (Oral Suspension) G 3

C1

Acy

clovir

Acyclovir (Oral Tablet) G 1 ¨C1

Acy

clovir

Sodium Acyclovir Sodium (Intravenous Solution) G 4 B/D, PA C1

Famciclo

vir

Famciclovir (Oral Tablet) G 3 QL C1

Vala

cycl

ovir HCl

Valacyclovir HCl (Oral Tablet) G 3 QL B1

Anti-HIV Agents, Integrase Inhibitors (INSTI)C1

Bikt

arvy

Biktarvy (Oral Tablet) B 5 DL; QL C1

Dovato

Dovato (Oral Tablet) B 5 DL; QL C1

Genvoya

Genvoya (Oral Tablet) B 5 DL; QL C1

Isen

tres

s HD

Isentress HD (Oral Tablet) B 5 DL; QL C1

Isen

tress

Isentress (Oral Packet) B 4 QL C1

Isentres

s

Isentress (Oral Tablet) B 5 DL; QL C1

Isentres

s

Isentress (100MG Oral Tablet Chewable) B 4 QL C1

Isen

tres

s

Isentress (25MG Oral Tablet Chewable) B 3 QL C1

Julu

ca

Juluca (Oral Tablet) B 5 DL; QL C1

Strib

ild

Stribild (Oral Tablet) B 5 DL; QL C1

Tivicay

Tivicay (10MG Oral Tablet) B 4 QL C1

Tivicay

Tivicay (25MG Oral Tablet, 50MG Oral Tablet) B 5 DL; QL B1

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)C1

Atri

pla

Atripla (Oral Tablet) B 5 DL; QL C1

Compl

era

Complera (Oral Tablet) B 5 DL; QL C1

Delstrigo

Delstrigo (Oral Tablet) B 5 DL; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Edurant

Edurant (Oral Tablet) B 5 DL; QL C1

Efaviren

z

Efavirenz (Oral Capsule) G 4 QL C1

Efav

iren

z

Efavirenz (Oral Tablet) G 4 QL C1

Intel

ence

Intelence (100MG Oral Tablet, 200MG Oral Tablet) B 5 DL; QL C1

Intelenc

e

Intelence (25MG Oral Tablet) B 4 QL C1

Nevirapi

ne ER

Nevirapine ER (Oral Tablet Extended Release 24 Hour) G 4 QL C1

Nevi

rapi

ne

Nevirapine (Oral Suspension) G 4 QL C1

Nevi

rapine

Nevirapine (Oral Tablet Immediate Release) G 3 QL C1

Pifel

tro

Pifeltro (Oral Tablet) B 5 DL; QL C1

Symfi Lo

Symfi Lo (Oral Tablet) B 5 DL; QL C1

Symfi

Symfi (Oral Tablet) B 5 DL; QL B1

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)C1

Aba

cavir

Sulfate Abacavir Sulfate (Oral Solution) G 4 QL C1

Abacavir

Sulfate Abacavir Sulfate (Oral Tablet) G 4 QL C1

Abacavir

Sulf

ate-

Lamivudi

ne Abacavir Sulfate-Lamivudine (Oral Tablet) G 4 QL C1

Aba

cavir

-Lam

ivudine-

Zidovudi

ne Abacavir-Lamivudine-Zidovudine (Oral Tablet) G 5 DL; QL C1

Cim

duo

Cimduo (Oral Tablet) B 5 DL; QL C1

Des

covy

Descovy (Oral Tablet) B 5 DL; QL C1

Didanosi

ne

Didanosine (250MG Oral Capsule Delayed Release,

400MG Oral Capsule Delayed Release)G 3 QL

C1

Emt

riva

Emtriva (Oral Capsule) B 4 QL C1

Emt

riva

Emtriva (Oral Solution) B 4 QL C1

Lam

ivudine

Lamivudine (10MG/ML Oral Solution) G 3 QL C1

Lamivudi

ne

Lamivudine (150MG Oral Tablet, 300MG Oral Tablet) G 3 QL C1

Lamivudi

ne-Zido

vudi

ne Lamivudine-Zidovudine (Oral Tablet) G 4 QL C1

Ode

fsey

Odefsey (Oral Tablet) B 5 DL; QL C1

Stav

udine

Stavudine (Oral Capsule) G 3 QL C1

Tenofov

ir

Disoprox

il Fum

arat

e Tenofovir Disoproxil Fumarate (Oral Tablet) G 4 QL C1

Triumeq

Triumeq (Oral Tablet) B 5 DL; QL C1

Truv

ada

Truvada (Oral Tablet) B 5 DL; QL C1

Vire

ad

Viread (Oral Powder) B 5 DL; QL C1

Vire

ad

Viread (150MG Oral Tablet, 200MG Oral Tablet,

250MG Oral Tablet)B 5 DL; QL

C1

Zidovudi

ne

Zidovudine (Oral Capsule) G 3 QL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Zidovudi

ne

Zidovudine (Oral Syrup) G 3 QL C1

Zidovudi

ne

Zidovudine (Oral Tablet) G 3 QL B1

Anti-HIV Agents, OtherC1

Fuz

eon

Fuzeon (Subcutaneous Solution Reconstituted) B 5 DL; QL C1

Selzentr

y

Selzentry (Oral Solution) B 5 DL; QL C1

Selzentr

y

Selzentry (150MG Oral Tablet, 300MG Oral Tablet,


C1

Selz

entr

y

Selzentry (25MG Oral Tablet) B 3 QL C1

Tyb

ost

Tybost (Oral Tablet) B 4 QL B1

Anti-HIV Agents, Protease InhibitorsC1

Aptivus

Aptivus (Oral Capsule) B 5 DL; QL C1

Aptivus

Aptivus (Oral Solution) B 5 DL; QL C1

Ataz

anavir

Sulf

ate Atazanavir Sulfate (Oral Capsule) G 4 QL C1

Crixi

van

Crixivan (Oral Capsule) B 4 QL C1

Evotaz

Evotaz (Oral Tablet) B 5 DL; QL C1

Fosamp

renavir

Calc

ium Fosamprenavir Calcium (Oral Tablet) G 5 DL; QL C1

Invir

ase

Invirase (Oral Tablet) B 5 DL; QL C1

Kale

tra

Kaletra (100-25MG Oral Tablet) B 4 QL C1

Kale

tra

Kaletra (200-50MG Oral Tablet) B 5 DL; QL C1

Lexiva

Lexiva (Oral Suspension) B 4 QL C1

Lopi

navi

r-Rito

navir Lopinavir-Ritonavir (Oral Solution) G 4 QL C1

Nor

vir

Norvir (Oral Packet) B 4 QL C1

Nor

vir

Norvir (Oral Solution) B 4 QL C1

Prezcobi

x

Prezcobix (Oral Tablet) B 5 DL; QL C1

Prezista

Prezista (Oral Suspension) B 5 DL; QL C1

Prez

ista

Prezista (150MG Oral Tablet, 600MG Oral Tablet,


C1

Prez

ista

Prezista (75MG Oral Tablet) B 4 QL C1

Reyataz

Reyataz (Oral Packet) B 5 DL; QL C1

Ritonavi

r

Ritonavir (Oral Tablet) G 3 QL C1

Sym

tuza

Symtuza (Oral Tablet) B 5 DL; QL C1

Vira

cept

Viracept (Oral Tablet) B 5 DL; QL B1

Anti-influenza AgentsC1

Oseltami

vir

Phosph

ate Oseltamivir Phosphate (Oral Capsule) G 3 QL C1

Oseltami

vir Pho

sphate Oseltamivir Phosphate (Oral Suspension Reconstituted) G 3 QL C1

Rele

nza Disk

hale

r Relenza Diskhaler (Inhalation Aerosol Powder Breath

Activated)B 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Rimanta

dine

HCl

Rimantadine HCl (Oral Tablet) G 4

C1

Xofluza

Xofluza (40 MG Dose) (Oral Tablet Therapy Pack) B 3 QL C1

Xofl

uza

Xofluza (80 MG Dose) (Oral Tablet Therapy Pack) B 3 QL A1

AnxiolyticsB1

Anxiolytics, OtherC1

Buspiro

ne HCl

Buspirone HCl (Oral Tablet) G 2 ¨C1

Hyd

roxy

zine HCl

Hydroxyzine HCl (Oral Syrup) G 3

C1

Hyd

roxyzine

HCl

Hydroxyzine HCl (Oral Tablet) G 3

C1

Hyd

roxyzine

Pamoate Hydroxyzine Pamoate (Oral Capsule) G 3

B1

BenzodiazepinesC1

Alprazol

am

Alprazolam (Oral Tablet Immediate Release) G 1 QL ¨C1

Chlo

rdiazep

oxid

e HCl Chlordiazepoxide HCl (Oral Capsule) G 2 ¨C1

Clon

azepam

Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)

G 2 QL ¨C1

Clonaze

pam

ODT Clonazepam ODT (0.125MG Oral Tablet Dispersible,

0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral

Tablet Dispersible)

G 4 QL

C1

Cloraze

pate

Dip

otassiu

m Clorazepate Dipotassium (Oral Tablet) G 3 QL C1

Diaz

epa

m Inte

nsol Diazepam Intensol (5MG/ML Oral Concentrate) G 2 QL ¨C1

Diaz

epam

Diazepam (5MG/5ML Oral Solution) G 2 ¨C1

Diaz

epam

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)

G 2 QL ¨C1

Lorazep

am Inte

nsol Lorazepam Intensol (Oral Concentrate) G 2 QL ¨C1

Lora

zep

am

Lorazepam (Oral Tablet) G 1 QL ¨A1

Bipolar AgentsB1

Mood StabilizersC1

Divalpro

ex

Sodium

ER Divalproex Sodium ER (Oral Tablet Extended Release 24

Hour)G 2 ¨

C1

Divalpro

ex Sodi

um Divalproex Sodium (Oral Capsule Delayed Release

Sprinkle)G 2 ¨

C1

Diva

lpro

ex Sodi

um Divalproex Sodium (Oral Tablet Delayed Release) G 2 ¨C1

Lithi

um Car

bonate

ER Lithium Carbonate ER (Oral Tablet Extended Release) G 2 ¨C1

Lithium

Car

bonate Lithium Carbonate (Oral Capsule) G 2 ¨C1

Lithium

Carbon

ate Lithium Carbonate (Oral Tablet Immediate Release) G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lithium

Lithium (Oral Solution) B 3

A1

Blood Glucose RegulatorsB1

Antidiabetic AgentsC1

Acar

bose

Acarbose (Oral Tablet) G 1 QL ¨C1

Bydureo

n

BCise Bydureon BCise (Subcutaneous Auto-Injector) B 3 QL C1

Bydureo

n

Bydureon (Subcutaneous Pen-Injector) B 3 QL C1

Byet

ta

10MCG

Pen Byetta 10MCG Pen (Subcutaneous Solution Pen-

Injector)B 4 QL

C1

Byet

ta 5M

CG

Pen Byetta 5MCG Pen (Subcutaneous Solution Pen-

Injector)B 4 QL

C1

Cycl

oset

Cycloset (Oral Tablet) B 4 PA; QL C1

Farxiga

Farxiga (Oral Tablet) B 3 QL C1

Glimepiri

de

Glimepiride (Oral Tablet) G 1 QL ¨C1

Glipi

zide ER

Glipizide ER (Oral Tablet Extended Release 24 Hour) G 1 QL ¨C1

Glipi

zide

Glipizide (Oral Tablet Immediate Release) G 1 QL ¨C1

Glipizide-

Metf

ormin

HCl Glipizide-Metformin HCl (Oral Tablet) G 1 QL ¨C1

Glyxamb

i

Glyxambi (Oral Tablet) B 3 QL C1

Jan

ume

t

Janumet (Oral Tablet Immediate Release) B 3 QL C1

Jan

umet XR

Janumet XR (Oral Tablet Extended Release 24 Hour) B 3 QL C1

Jan

uvia

Januvia (Oral Tablet) B 3 QL C1

Jardianc

e

Jardiance (Oral Tablet) B 3 QL C1

Jent

adu

eto

Jentadueto (Oral Tablet Immediate Release) B 3 QL C1

Jent

adueto

XR

Jentadueto XR (Oral Tablet Extended Release 24

Hour)B 3 QL

C1

Metf

ormin

HCl ER Metformin HCl ER (Oral Tablet Extended Release 24

Hour) (Generic Glucophage XR)G 1 QL ¨

C1

Metformi

n

HCl

Metformin HCl (500MG/5ML Oral Solution) G 4 QL C1

Metformi

n HCl

Metformin HCl (1000MG Oral Tablet Immediate Release,

500MG Oral Tablet Immediate Release, 850MG Oral

Tablet Immediate Release)

G 1 QL ¨

C1

Migl

itol

Miglitol (Oral Tablet) G 4 QL C1

Nat

eglinide

Nateglinide (Oral Tablet) G 1 QL ¨C1

Ozempi

c

Ozempic (0.25 or 0.5MG/DOSE) (Subcutaneous

Solution Pen-Injector)B 3 QL

C1

Ozempi

c

Ozempic (1MG/DOSE) (Subcutaneous Solution Pen-

Injector)B 3 QL

C1

Piog

litaz

one HCl

Pioglitazone HCl (Oral Tablet) G 1 QL ¨C1

Piog

litazone

HCl-

Glimepiri

de Pioglitazone HCl-Glimepiride (Oral Tablet) G 1 QL ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pioglitaz

one

HCl-Metf

ormin

HCl Pioglitazone HCl-Metformin HCl (Oral Tablet) G 1 QL ¨C1

Repagli

nide

Repaglinide (Oral Tablet) G 1 QL ¨C1

Rio

met

ER

Riomet ER (Oral Suspension Reconstituted ER) B 4 QL C1

Ryb

elsus

Rybelsus (Oral Tablet) B 3 QL C1

Soliqua

Soliqua (Subcutaneous Solution Pen-Injector) B 3 QL C1

SymlinP

en 120

SymlinPen 120 (Subcutaneous Solution Pen-Injector) B 5 PA; DL C1

Sym

linP

en 60

SymlinPen 60 (Subcutaneous Solution Pen-Injector) B 5 PA; DL C1

Synj

ardy

Synjardy (Oral Tablet Immediate Release) B 3 QL C1

Synj

ardy XR

Synjardy XR (Oral Tablet Extended Release 24 Hour) B 3 QL C1

Tradjent

a

Tradjenta (Oral Tablet) B 3 QL C1

Trulicity

Trulicity (Subcutaneous Solution Pen-Injector) B 3 QL C1

Vict

oza

Victoza (Subcutaneous Solution Pen-Injector) B 3 QL C1

Xigd

uo XR

Xigduo XR (Oral Tablet Extended Release 24 Hour) B 3 QL B1

Glycemic AgentsC1

Baqsimi

Two Pac

k Baqsimi Two Pack (Nasal Powder) B 3

C1

Diaz

oxid

e

Diazoxide (Oral Suspension) G 5 DL C1

Gluc

aGen

Hyp

oKit GlucaGen HypoKit (Injection Solution Reconstituted) B 4

C1

Gluc

agon

Glucagon (Injection Kit) (Lilly) B 3

C1

Gvoke

HypoPe

n 2-

Pack Gvoke HypoPen 2-Pack (Subcutaneous Solution Auto-

Injector)B 3

C1

Gvo

ke

PFS

Gvoke PFS (Subcutaneous Solution Prefilled Syringe) B 3

B1

InsulinsC1

Hu

malog

Junior

Kwi

kPen Humalog Junior KwikPen (Subcutaneous Solution

Pen-Injector)B 3

C1

Humal

og

KwikPe

n Humalog KwikPen (Subcutaneous Solution Pen-

Injector)B 3

C1

Humal

og Mix

50/5

0 Kwi

kPen Humalog Mix 50/50 KwikPen (Subcutaneous

Suspension Pen-Injector)B 3

C1

Hu

mal

og Mix

50/50 Humalog Mix 50/50 (Subcutaneous Suspension) B 3

C1

Hu

malog

Mix 75/2

5

KwikPe

n Humalog Mix 75/25 KwikPen (Subcutaneous

Suspension Pen-Injector)B 3

C1

Humal

og

Mix 75/2

5 Humalog Mix 75/25 (Subcutaneous Suspension) B 3

C1

Humal

og

Humalog (Subcutaneous Solution) B 3

C1

Hu

mal

og

Humalog (Subcutaneous Solution Cartridge) B 3




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Humuli

n

70/30

KwikPe

n Humulin 70/30 KwikPen (Subcutaneous Suspension

Pen-Injector)B 3

C1

Humuli

n 70/3

0 Humulin 70/30 (Subcutaneous Suspension) B 3

C1

Hu

muli

n N Kwi

kPen Humulin N KwikPen (Subcutaneous Suspension Pen-

Injector)B 3

C1

Hu

mulin N

Humulin N (Subcutaneous Suspension) B 3

C1

Humuli

n R

Humulin R (Injection Solution) B 3

C1

Humuli

n R U-50

0 Humulin R U-500 (Concentrated) (Subcutaneous

Solution)B 3

C1

Hu

muli

n R U-50

0 Kwi

kPe

n Humulin R U-500 KwikPen (Subcutaneous Solution

Pen-Injector)B 3

C1

Insul

in Lisp

ro

Insulin Lispro (1 Unit Dial) (Subcutaneous Solution

Pen-Injector) (Brand Equivalent Humalog)B 3

C1

Insul

in Lisp

ro Juni

or Kwi

kPe

n Insulin Lispro Junior KwikPen (Subcutaneous

Solution Pen-Injector) (Brand Equivalent Humalog)B 3

C1

Insulin

Lisp

ro Prot

& Lisp

ro Insulin Lispro Prot & Lispro (Subcutaneous

Suspension Pen-Injector) (Brand Equivalent Humalog)B 3

C1

Insulin

Lispro

Insulin Lispro (Subcutaneous Solution) (Brand

Equivalent Humalog)B 3

C1

Lant

us Solo

Star

Lantus SoloStar (Subcutaneous Solution Pen-Injector) B 3

C1

Lant

us

Lantus (Subcutaneous Solution) B 3

C1

Levemir

FlexTou

ch Levemir FlexTouch (Subcutaneous Solution Pen-

Injector)B 3

C1

Levemir

Levemir (Subcutaneous Solution) B 3

C1

Touj

eo

Max Solo

Star Toujeo Max SoloStar (Subcutaneous Solution Pen-

Injector)B 3

C1

Touj

eo Solo

Star

Toujeo SoloStar (Subcutaneous Solution Pen-Injector) B 3

C1

Tres

iba Flex

Touch Tresiba FlexTouch (Subcutaneous Solution Pen-

Injector)B 3

C1

Tresiba

Tresiba (Subcutaneous Solution) B 3

A1

Blood Products and ModifiersB1

AnticoagulantsC1

Eliq

uis Start

er Pac

k Eliquis Starter Pack (Oral Tablet) B 3 QL C1

Eliquis

Eliquis (Oral Tablet) B 3 QL C1

Enoxap

arin Sodi

um Enoxaparin Sodium (Subcutaneous Solution) G 4 QL C1

Fon

dap

arinux

Sodium Fondaparinux Sodium (10MG/0.8ML Subcutaneous

Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/

0.6ML Subcutaneous Solution)

G 5 DL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Fondap

arin

ux Sodi

um Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous

Solution)G 4

C1

Heparin

Sodium

Heparin Sodium (10000UNIT/ML Injection Solution,

20000UNIT/ML Injection Solution, 5000UNIT/ML

Injection Solution)

G 3

C1

Hep

arin

Sodium

Heparin Sodium (1000UNIT/ML Injection Solution) G 3 B/D, PA C1

Jant

oven

Jantoven (Oral Tablet) G 1 ¨C1

Warfarin

Sodi

um

Warfarin Sodium (Oral Tablet) G 1 ¨C1

Xarelto

Xarelto (Oral Tablet) B 3 QL C1

Xare

lto

Starter

Pack Xarelto Starter Pack (Oral Tablet Therapy Pack) B 3 QL

B1

Blood Products and Modifiers, OtherC1

Ana

grelide

HCl

Anagrelide HCl (Oral Capsule) G 3

C1

Aranesp

Aranesp (Albumin Free) (100MCG/ML Injection

Solution, 200MCG/ML Injection Solution, 300MCG/

ML Injection Solution)

B 5 PA; DL

C1

Aranesp

Aranesp (Albumin Free) (25MCG/ML Injection

Solution, 40MCG/ML Injection Solution, 60MCG/ML

Injection Solution)

B 4 PA

C1

Aran

esp

Aranesp (Albumin Free) (100MCG/0.5ML Injection

Solution Prefilled Syringe, 150MCG/0.3ML Injection



Solution Prefilled Syringe, 500MCG/ML Injection

Solution Prefilled Syringe)

B 5 PA; DL

C1

Aran

esp

Aranesp (Albumin Free) (10MCG/0.4ML Injection




Solution Prefilled Syringe)

B 4 PA

C1

Granix

Granix (Subcutaneous Solution) B 5 ST; DL C1

Granix

Granix (Subcutaneous Solution Prefilled Syringe) B 5 ST; DL C1

Leu

kine

Leukine (Injection Solution Reconstituted) B 5 PA; DL C1

Neul

asta

Neulasta (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Neu

pogen

Neupogen (Injection Solution) B 5 ST; DL C1

Neupog

en

Neupogen (Injection Solution Prefilled Syringe) B 5 ST; DL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Procrit

Procrit (10000UNIT/ML Injection Solution, 2000UNIT/

ML Injection Solution, 3000UNIT/ML Injection

Solution, 4000UNIT/ML Injection Solution)

B 4 PA

C1

Procrit

Procrit (20000UNIT/ML Injection Solution,

40000UNIT/ML Injection Solution)B 5 PA; DL

C1

Pro

mac

ta

Promacta (Oral Packet) B 5 PA; LA; DL; QL C1

Pro

macta

Promacta (Oral Tablet) B 5 PA; LA; DL; QL C1

Retacrit

Retacrit (Injection Solution) B 4 PA C1

Udenyca

Udenyca (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Zarx

io

Zarxio (Injection Solution Prefilled Syringe) B 5 DL B1

Hemostasis AgentsC1

Tran

examic

Acid

Tranexamic Acid (Oral Tablet) G 3

B1

Platelet Modifying AgentsC1

Aspirin-

Dipyrida

mole

ER Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)

G 3 QL C1

Brili

nta

Brilinta (Oral Tablet) B 3 QL C1

Cabl

ivi

Cablivi (Injection Kit) B 5 PA; LA; DL; QL C1

Cilostaz

ol

Cilostazol (Oral Tablet) G 2 ¨C1

Clopido

grel Bisu

lfate Clopidogrel Bisulfate (75MG Oral Tablet) G 2 QL ¨C1

Pras

ugre

l HCl

Prasugrel HCl (Oral Tablet) G 3 QL A1

Cardiovascular AgentsB1

Alpha-adrenergic AgonistsC1

Clonidin

e HCl

Clonidine HCl (Oral Tablet Immediate Release) G 1 ¨C1

Clon

idin

e

Clonidine (Transdermal Patch Weekly) G 4

C1

Met

hyldopa

Methyldopa (Oral Tablet) G 3

C1

Mid

odrine

HCl

Midodrine HCl (Oral Tablet) G 3

C1

Northera

Northera (Oral Capsule) B 5 PA; LA; DL; QL B1

Alpha-adrenergic Blocking AgentsC1

Dox

azos

in Mes

ylate Doxazosin Mesylate (Oral Tablet) G 2 ¨C1

Phe

noxybe

nzamin

e

HCl Phenoxybenzamine HCl (Oral Capsule) G 5 DL C1

Prazosin

HCl

Prazosin HCl (Oral Capsule) G 2 ¨B1

Angiotensin II Receptor AntagonistsC1

Can

des

artan

Cilexetil Candesartan Cilexetil (Oral Tablet) G 1 QL ¨C1

Edar

bi

Edarbi (Oral Tablet) B 4 QL C1

Irbe

sartan

Irbesartan (Oral Tablet) G 1 QL ¨C1

Losarta

n

Potassiu

m Losartan Potassium (Oral Tablet) G 1 QL ¨C1

Olmesar

tan Med

oxomil Olmesartan Medoxomil (Oral Tablet) G 1 QL ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Telmisa

rtan

Telmisartan (Oral Tablet) G 1 QL ¨C1

Valsarta

n

Valsartan (Oral Tablet) G 1 QL ¨B1

Angiotensin-converting Enzyme (ACE) InhibitorsC1

Ben

azepril

HCl

Benazepril HCl (Oral Tablet) G 1 QL ¨C1

Captopri

l

Captopril (Oral Tablet) G 1 QL ¨C1

Enalapril

Mal

eate Enalapril Maleate (Oral Tablet) G 1 QL ¨C1

Fosi

nopr

il Sodi

um Fosinopril Sodium (Oral Tablet) G 1 QL ¨C1

Lisin

opril

Lisinopril (Oral Tablet) G 1 QL ¨C1

Moe

xipril HCl

Moexipril HCl (Oral Tablet) G 1 QL ¨C1

Perindo

pril

Erbumi

ne Perindopril Erbumine (Oral Tablet) G 1 QL ¨C1

Quinapril

HCl

Quinapril HCl (Oral Tablet) G 1 QL ¨C1

Ram

ipril

Ramipril (Oral Capsule) G 1 QL ¨C1

Tran

dolapril

Trandolapril (Oral Tablet) G 1 QL ¨B1

AntiarrhythmicsC1

Amiodar

one HCl

Amiodarone HCl (200MG Oral Tablet) G 1 ¨C1

Dof

etili

de

Dofetilide (Oral Capsule) G 4

C1

Flec

ainide

Acet

ate Flecainide Acetate (Oral Tablet) G 2 ¨C1

Mex

iletine

HCl

Mexiletine HCl (Oral Capsule) G 3

C1

Multaq

Multaq (Oral Tablet) B 3 QL C1

Pac

eron

e

Pacerone (200MG Oral Tablet) G 1 ¨C1

Pro

pafenon

e

HCl ER Propafenone HCl ER (Oral Capsule Extended Release

12 Hour)G 4

C1

Pro

pafenon

e HCl Propafenone HCl (Oral Tablet) G 2 ¨C1

Quinidin

e

Gluconat

e ER Quinidine Gluconate ER (Oral Tablet Extended Release) G 4

C1

Quinidin

e Sulf

ate Quinidine Sulfate (Oral Tablet) G 2 ¨C1

Sota

lol

HCl AF

Sotalol HCl AF (Oral Tablet) G 2 ¨C1

Sota

lol HCl

Sotalol HCl (Oral Tablet) G 2 ¨B1

Beta-adrenergic Blocking AgentsC1

Acebuto

lol HCl

Acebutolol HCl (Oral Capsule) G 2 ¨C1

Aten

olol

Atenolol (Oral Tablet) G 1 ¨C1

Beta

xolol

HCl

Betaxolol HCl (Oral Tablet) G 3

C1

Biso

prolol

Fumarat

e Bisoprolol Fumarate (Oral Tablet) G 2 ¨C1

Bystolic

Bystolic (Oral Tablet) B 3 QL C1

Carvedil

ol

Carvedilol (Oral Tablet) G 1 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Labetal

ol

HCl

Labetalol HCl (Oral Tablet) G 2 ¨C1

Metopr

olol Suc

cinate

ER Metoprolol Succinate ER (Oral Tablet Extended Release 24 Hour)

G 1 ¨C1

Met

opr

olol Tartr

ate Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral

Tablet, 50MG Oral Tablet)G 1 ¨

C1

Nad

olol

Nadolol (Oral Tablet) G 4

C1

Pindolol

Pindolol (Oral Tablet) G 3

C1

Propran

olol HCl

ER Propranolol HCl ER (Oral Capsule Extended Release 24 Hour)

G 2 ¨C1

Pro

pran

olol HCl

Propranolol HCl (Oral Solution) G 2 ¨C1

Pro

pranolol

HCl

Propranolol HCl (Oral Tablet) G 2 ¨B1

Calcium Channel Blocking Agents, DihydropyridinesC1

Amlodip

ine

Besylate Amlodipine Besylate (Oral Tablet) G 1 ¨C1

Felodipi

ne ER

Felodipine ER (Oral Tablet Extended Release 24 Hour) G 2 ¨C1

Nica

rdipine

HCl

Nicardipine HCl (Oral Capsule) G 4

C1

Nife

dipine

ER

Nifedipine ER (Oral Tablet Extended Release 24 Hour) G 2 QL ¨C1

Nifedipi

ne

ER Os

motic

Rele

ase Nifedipine ER Osmotic Release (Oral Tablet Extended

Release 24 Hour)G 2 QL ¨

C1

Nimodip

ine

Nimodipine (Oral Capsule) G 4

C1

Nym

alize

Nymalize (6MG/ML Oral Solution) B 5 DL B1

Calcium Channel Blocking Agents, NondihydropyridinesC1

Carti

a XT

Cartia XT (Oral Capsule Extended Release 24 Hour) G 2 ¨C1

Diltiaze

m HCl

ER

Beads Diltiazem HCl ER Beads (360MG Oral Capsule Extended

Release 24 Hour, 420MG Oral Capsule Extended

Release 24 Hour)

G 2 ¨

C1

Dilti

aze

m HCl

ER Coa

ted

Beads Diltiazem HCl ER Coated Beads (120MG Oral Capsule

Extended Release 24 Hour, 180MG Oral Capsule



Extended Release 24 Hour)

G 2 ¨

C1

Dilti

azem

HCl

ER Diltiazem HCl ER (Oral Capsule Extended Release 12 Hour)

G 2 ¨C1

Dilti

azem

HCl

Diltiazem HCl (Oral Tablet Immediate Release) G 2 ¨C1

Dilt-XR

Dilt-XR (Oral Capsule Extended Release 24 Hour) G 2 ¨C1

Matzim

LA

Matzim LA (Oral Tablet Extended Release 24 Hour) G 2 ¨C1

Tazt

ia

XT

Taztia XT (Oral Capsule Extended Release 24 Hour) G 2 ¨C1

Tiad

ylt ER

Tiadylt ER (Oral Capsule Extended Release 24 Hour) G 2 ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Verapam

il

HCl ER Verapamil HCl ER (100MG Oral Capsule Extended




Release 24 Hour)

B 3

C1

Verapam

il HCl

ER Verapamil HCl ER (120MG Oral Capsule Extended


Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour)

G 3

C1

Vera

pam

il HCl

ER Verapamil HCl ER (Oral Tablet Extended Release) G 2 ¨C1

Vera

pamil

HCl

Verapamil HCl (Oral Tablet Immediate Release) G 2 ¨B1

Cardiovascular Agents, OtherC1

Acetazol

amide

ER Acetazolamide ER (Oral Capsule Extended Release 12 Hour)

G 4

C1

Acet

azol

amide

Acetazolamide (Oral Tablet) G 3

C1

Alis

kiren

Fum

arate Aliskiren Fumarate (Oral Tablet) G 4 QL C1

Amil

oride-

Hydroch

lorothiazi

de Amiloride-Hydrochlorothiazide (Oral Tablet) G 2 ¨C1

Amlodip

ine-

Atorvast

atin Amlodipine-Atorvastatin (Oral Tablet) G 2 QL ¨C1

Amlodip

ine-Ben

azepril Amlodipine-Benazepril (Oral Capsule) G 1 QL ¨C1

Aml

odipine-

Olm

esartan Amlodipine-Olmesartan (Oral Tablet) G 2 QL ¨C1

Aml

odipine-

Valsarta

n Amlodipine-Valsartan (Oral Tablet) G 2 QL ¨C1

Amlodip

ine-

Valsarta

n-HCT

Z Amlodipine-Valsartan-HCTZ (Oral Tablet) G 2 QL ¨C1

Atenolol-

Chlorthal

idon

e Atenolol-Chlorthalidone (Oral Tablet) G 1 ¨C1

Ben

aze

pril-Hyd

rochlorot

hiazide Benazepril-Hydrochlorothiazide (Oral Tablet) G 1 QL ¨C1

BiDil

BiDil (Oral Tablet) B 3 QL C1

Biso

prolol-

Hydroch

lorothiazi

de Bisoprolol-Hydrochlorothiazide (Oral Tablet) G 2 QL ¨C1

Candes

artan

Cile

xetil-HCT

Z Candesartan Cilexetil-HCTZ (Oral Tablet) G 1 QL ¨C1

Cap

topri

l-Hyd

rochlorot

hiazi

de Captopril-Hydrochlorothiazide (Oral Tablet) G 1 QL ¨C1

Corl

anor

Corlanor (Oral Solution) B 4 PA; QL C1

Corl

anor

Corlanor (Oral Tablet) B 4 PA; QL C1

Demse

r

Demser (Oral Capsule) B 5 DL C1

Digitek

Digitek (Oral Tablet) G 2 ¨C1

Dig

ox

Digox (Oral Tablet) G 2 ¨C1

Dig

oxin

Digoxin (Oral Solution) G 3

C1

Digoxin

Digoxin (Oral Tablet) G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Edarbycl

or

Edarbyclor (Oral Tablet) B 4 QL C1

Enalapril

-Hyd

rochlorot

hiazi

de Enalapril-Hydrochlorothiazide (Oral Tablet) G 1 QL ¨C1

Entr

esto

Entresto (Oral Tablet) B 3 QL C1

Fosi

nopril

Sodium-

HCT

Z Fosinopril Sodium-HCTZ (Oral Tablet) G 1 QL ¨C1

Irbesart

an-

Hydroch

lorothiazi

de Irbesartan-Hydrochlorothiazide (Oral Tablet) G 1 QL ¨C1

Lanoxin

Lanoxin (Oral Tablet) B 4

C1

Lisin

opril

-Hyd

rochlorot

hiazi

de Lisinopril-Hydrochlorothiazide (Oral Tablet) G 1 QL ¨C1

Los

artan

Pota

ssium-

HCTZ Losartan Potassium-HCTZ (Oral Tablet) G 1 QL ¨C1

Met

hyldopa-

Hydroch

lorothiazi

de Methyldopa-Hydrochlorothiazide (Oral Tablet) G 3

C1

Metopr

olol-

Hydroch

lorothiazi

de Metoprolol-Hydrochlorothiazide (Oral Tablet) G 2 ¨C1

Olmesar

tan Med

oxomil-

HCT

Z Olmesartan Medoxomil-HCTZ (Oral Tablet) G 1 QL ¨C1

Olm

esartan-

Aml

odipine-

HCTZ Olmesartan-Amlodipine-HCTZ (Oral Tablet) G 2 QL ¨C1

Pent

oxifylline

ER

Pentoxifylline ER (Oral Tablet Extended Release) G 2 ¨C1

Propran

olol-

HCTZ Propranolol-HCTZ (Oral Tablet) G 2 ¨C1

Quinapril

-Hyd

roch

lorothiazi

de Quinapril-Hydrochlorothiazide (Oral Tablet) G 1 QL ¨C1

Ran

olazi

ne ER

Ranolazine ER (Oral Tablet Extended Release 12 Hour) G 3 QL C1

Spir

onolacto

ne-

HCTZ Spironolactone-HCTZ (Oral Tablet) G 2 ¨C1

Tel

misartan-

Amlodip

ine Telmisartan-Amlodipine (Oral Tablet) G 1 QL ¨C1

Telmisa

rtan-HCT

Z Telmisartan-HCTZ (Oral Tablet) G 1 QL ¨C1

Tria

mter

ene-HCT

Z Triamterene-HCTZ (Oral Capsule) G 2 ¨C1

Tria

mterene-

HCT

Z Triamterene-HCTZ (Oral Tablet) G 2 ¨C1

Vals

artan-

Hydroch

lorot

hiazide Valsartan-Hydrochlorothiazide (Oral Tablet) G 1 QL ¨

B1

Diuretics, LoopC1

Bumetan

ide

Bumetanide (Injection Solution) G 4

C1

Bum

etan

ide

Bumetanide (Oral Tablet) G 1 ¨C1

Etha

crynic

Acid

Ethacrynic Acid (Oral Tablet) G 4

C1

Furosem

ide

Furosemide (Injection Solution) G 4 B/D, PA C1

Furosem

ide

Furosemide (Oral Solution) G 1 ¨C1

Furo

sem

ide

Furosemide (Oral Tablet) G 1 ¨C1

Tors

emide

Torsemide (Oral Tablet) G 2 ¨B1

Diuretics, Potassium-sparingC1

Amilorid

e

HCl

Amiloride HCl (Oral Tablet) G 2 ¨C1

Eplereno

ne

Eplerenone (Oral Tablet) G 3

C1

Spir

onolacto

ne

Spironolactone (Oral Tablet) G 2 ¨C1

Tria

mterene

Triamterene (Oral Capsule) G 4

B1

Diuretics, ThiazideC1

Chlorthal

idone

Chlorthalidone (Oral Tablet) G 2 ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Diuril

Diuril (Oral Suspension) B 4

C1

Hydroch

lorothiazi

de Hydrochlorothiazide (Oral Capsule) G 1 ¨C1

Hyd

roch

lorothiazi

de Hydrochlorothiazide (Oral Tablet) G 1 ¨C1

Inda

pamide

Indapamide (Oral Tablet) G 2 ¨C1

Metolaz

one

Metolazone (Oral Tablet) G 3

B1

Dyslipidemics, Fibric Acid DerivativesC1

Fen

ofibr

ate Micr

onized Fenofibrate Micronized (200MG Oral Capsule, 67MG

Oral Capsule)G 2 ¨

C1

Fen

ofibrate

Micr

onized Fenofibrate Micronized (134MG Oral Capsule) G 2 ¨C1

Fen

ofibrate

Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet) G 2 ¨C1

Fenofibr

ate

Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet) G 1 ¨C1

Fenofibr

ic Acid

Fenofibric Acid (Oral Capsule Delayed Release) G 3

C1

Ge

mfibrozil

Gemfibrozil (Oral Tablet) G 2 ¨B1

Dyslipidemics, HMG CoA Reductase InhibitorsC1

Atorvast

atin

Calcium Atorvastatin Calcium (Oral Tablet) G 1 QL ¨C1

Fluvasta

tin Sodi

um Fluvastatin Sodium (Oral Capsule) G 2 QL ¨C1

Lival

o

Livalo (Oral Tablet) B 3 QL C1

Lov

astatin

Lovastatin (Oral Tablet) G 1 QL ¨C1

Prav

astatin

Sodium Pravastatin Sodium (Oral Tablet) G 1 QL ¨C1

Rosuvas

tatin

Calc

ium Rosuvastatin Calcium (Oral Tablet) G 1 QL ¨C1

Sim

vast

atin

Simvastatin (Oral Tablet) G 1 QL ¨B1

Dyslipidemics, OtherC1

Chol

estyrami

ne Ligh

t Cholestyramine Light (Oral Powder) G 4

C1

Cholesty

rami

ne

Cholestyramine (Oral Packet) G 4

C1

Coleseve

lam HCl

Colesevelam HCl (Oral Packet) G 3

C1

Cole

seve

lam HCl

Colesevelam HCl (Oral Tablet) G 3

C1

Cole

stipol

HCl

Colestipol HCl (Oral Packet) G 4

C1

Colestip

ol

HCl

Colestipol HCl (Oral Tablet) G 3

C1

Ezetimib

e

Ezetimibe (Oral Tablet) G 2 QL ¨C1

Ezet

imib

e-Sim

vastatin Ezetimibe-Simvastatin (Oral Tablet) G 3 QL C1

Juxt

apid

Juxtapid (Oral Capsule) B 5 PA; LA; DL C1

Niac

in ER

Niacin ER (Antihyperlipidemic) (Oral Tablet Extended

Release)G 3

C1

Niacor

Niacor (Oral Tablet) G 4




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Omega-

3-

Acid Ethy

l Este

rs Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic

Lovaza)G 4 QL

C1

Praluent

Praluent (Subcutaneous Solution Auto-Injector) B 3 PA; LA; QL C1

Prev

alite

Prevalite (Oral Packet) G 4

C1

Rep

atha

Pushtro

nex

System Repatha Pushtronex System (Subcutaneous Solution

Cartridge)B 3 PA; QL

C1

Repatha

Repatha (Subcutaneous Solution Prefilled Syringe) B 3 PA; QL C1

Repatha

Sure

Clic

k Repatha SureClick (Subcutaneous Solution Auto-

Injector)B 3 PA; QL

C1

Vas

cep

a

Vascepa (Oral Capsule) B 4

B1

Vasodilators, Direct-acting ArterialC1

Hyd

ralazine

HCl

Hydralazine HCl (Oral Tablet) G 2 ¨C1

Minoxid

il

Minoxidil (Oral Tablet) G 2 ¨B1

Vasodilators, Direct-acting Arterial/VenousC1

Isos

orbide

Dinit

rate Isosorbide Dinitrate (10MG Oral Tablet Immediate

Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet

Immediate Release)

G 2 ¨

C1

Isos

orbide

Mononitr

ate

ER Isosorbide Mononitrate ER (Oral Tablet Extended Release 24 Hour)

G 2 ¨C1

Isosorbi

de

Mononitr

ate Isosorbide Mononitrate (Oral Tablet Immediate Release) G 2 ¨C1

Minitran

Minitran (Transdermal Patch 24 Hour) G 2 ¨C1

Nitr

o-

Bid

Nitro-Bid (Transdermal Ointment) G 4

C1

Nitr

oglyceri

n

Nitroglycerin (Tablet Sublingual) G 2 ¨C1

Nitr

oglyceri

n

Nitroglycerin (Transdermal Patch 24 Hour) G 2 ¨C1

Nitrogly

cerin

Nitroglycerin (Translingual Solution) G 3

C1

Nitr

osta

t

Nitrostat (Tablet Sublingual) B 3

C1

Rect

iv

Rectiv (Rectal Ointment) B 4 QL A1

Central Nervous System AgentsB1

Attention Deficit Hyperactivity Disorder Agents, AmphetaminesC1

Amphet

amine-

Dext

roamph

etamin

e ER

Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)

G 4 QL C1

Am

phet

amine-

Dextroa

mpheta

min

eAmphetamine-Dextroamphetamine (Oral Tablet) G 3 QL

C1

Dext

roamph

etamin

e

Sulfate

ER Dextroamphetamine Sulfate ER (Oral Capsule Extended

Release 24 Hour)G 4 QL

C1

Dextroa

mph

etamin

e Sulf

ate Dextroamphetamine Sulfate (Oral Tablet) G 4 QL C1

Vyvans

e

Vyvanse (Oral Capsule) B 4

C1

Vyv

ans

e

Vyvanse (Oral Tablet Chewable) B 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

B1

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesC1

Atomox

etine

HCl Atomoxetine HCl (Oral Capsule) G 4 QL C1

Clon

idin

e HCl

ER Clonidine HCl ER (Oral Tablet Extended Release 12

Hour)G 4 PA

C1

Dex

methylp

henidate

HCl

ER Dexmethylphenidate HCl ER (Oral Capsule Extended

Release 24 Hour)G 4

C1

Dexmet

hylp

henidate

HCl Dexmethylphenidate HCl (Oral Tablet) G 3 QL C1

Guanfac

ine HCl

ER Guanfacine HCl ER (Oral Tablet Extended Release 24 Hour)

G 4

C1

Met

hylp

henidate

HCl ER Methylphenidate HCl ER (10MG Oral Tablet Extended

Release, 20MG Oral Tablet Extended Release)G 4 QL

C1

Met

hylpheni

date

HCl Methylphenidate HCl (Oral Solution) G 4 QL C1

Met

hylpheni

date HCl Methylphenidate HCl (Oral Tablet Immediate Release)

(Generic Ritalin)G 3 QL

B1

Central Nervous System, OtherC1

Austedo

Austedo (Oral Tablet) B 5 PA; LA; DL; QL C1

Ingr

ezza

Ingrezza (Oral Capsule) B 5 PA; DL; QL C1

Ingr

ezza

Ingrezza (Oral Capsule Therapy Pack) B 5 PA; DL; QL C1

Nuedext

a

Nuedexta (Oral Capsule) B 4 PA; QL C1

Riluzole

Riluzole (Oral Tablet) G 3

C1

Tetr

abe

nazine

Tetrabenazine (Oral Tablet) G 5 PA; LA; DL; QL B1

Fibromyalgia AgentsC1

Driz

alma

Sprinkle Drizalma Sprinkle (Oral Capsule Delayed Release

Sprinkle)B 4 ST; QL

C1

Duloxeti

ne HCl

Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles,

60MG Oral Capsule Delayed Release Particles)

G 2 QL ¨

C1

Pre

gab

alin

Pregabalin (Oral Capsule) G 3 QL C1

Pre

gabalin

Pregabalin (Oral Solution) G 3 QL C1

Sav

ella

Savella (Oral Tablet) B 3

C1

Savella

Titra

tion Pac

k Savella Titration Pack (Oral Tablet) B 3

B1

Multiple Sclerosis AgentsC1

Aub

agio

Aubagio (Oral Tablet) B 5 LA; DL; QL C1

Avo

nex Pen

Avonex Pen (Intramuscular Auto-Injector Kit) B 5 DL; QL C1

Avonex

Prefi

lled

Avonex Prefilled (Intramuscular Prefilled Syringe Kit) B 5 DL; QL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Betasero

n

Betaseron (Subcutaneous Kit) B 5 DL; QL C1

Dalfamp

ridine

ER Dalfampridine ER (Oral Tablet Extended Release 12 Hour)

G 3 QL C1

Gile

nya

Gilenya (0.5MG Oral Capsule) B 5 DL; QL C1

Glati

ramer

Acetate Glatiramer Acetate (Subcutaneous Solution Prefilled

Syringe)G 5 DL; QL

C1

Glatopa

Glatopa (Subcutaneous Solution Prefilled Syringe) G 5 DL; QL C1

Mayzent

Mayzent (Oral Tablet) B 5 LA; DL; QL C1

Rebi

f

Rebidos

e Rebif Rebidose (Subcutaneous Solution Auto-

Injector)B 5 ST; DL; QL

C1

Rebi

f Rebi

dos

e Titra

tion Pac

k Rebif Rebidose Titration Pack (Subcutaneous

Solution Auto-Injector)B 5 ST; DL; QL

C1

Rebi

f

Rebif (Subcutaneous Solution Prefilled Syringe) B 5 ST; DL; QL C1

Rebif

Titra

tion Pac

k Rebif Titration Pack (Subcutaneous Solution Prefilled

Syringe)B 5 ST; DL; QL

C1

Tecfider

a Start

er Pac

k Tecfidera Starter Pack (Oral) B 5 LA; DL C1

Tecf

idera

Tecfidera (Oral Capsule Delayed Release) B 5 LA; DL; QL A1

Dental and Oral AgentsB1

Dental and Oral AgentsC1

Chlorhex

idine

Gluc

onate Chlorhexidine Gluconate (Mouth Solution) G 2 ¨C1

Pilo

carp

ine HCl

Pilocarpine HCl (Oral Tablet) G 4

C1

Tria

mcinolo

ne

Acetonid

e Triamcinolone Acetonide (Dental Paste) G 3

A1

Dermatological AgentsB1

Acne and Rosacea AgentsC1

Acitr

etin

Acitretin (Oral Capsule) G 4

C1

Ada

palene

Adapalene (External Cream) G 4

C1

Ada

palene

Adapalene (0.1% External Gel) G 3

C1

Amneste

em

Amnesteem (Oral Capsule) G 4 PA C1

Azelaic

Acid

Azelaic Acid (External Gel) G 4

C1

Ben

zoyl

Peroxid

e-Eryt

hromyci

n Benzoyl Peroxide-Erythromycin (External Gel) G 4

C1

Clar

avis

Claravis (Oral Capsule) G 4 PA C1

Clindam

ycin

Phosph

ate-Ben

zoyl

Peroxid

e

Clindamycin Phosphate-Benzoyl Peroxide (1-5% External

Gel)G 4

C1

Finacea

Finacea (External Foam) B 4

C1

Isotr

etin

oin

Isotretinoin (Oral Capsule) G 4 PA C1

Mirv

aso

Mirvaso (External Gel) B 4

C1

Myo

risan

Myorisan (Oral Capsule) G 4 PA C1

Tazarot

ene

Tazarotene (External Cream) G 4 PA


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Tretinoin

Tretinoin (External Cream) G 4 PA C1

Tretinoin

Tretinoin (0.01% External Gel, 0.025% External Gel) G 4 PA C1

Treti

noin

Micr

osphere Tretinoin Microsphere (External Gel) G 4 PA C1

Zen

atane

Zenatane (Oral Capsule) G 4 PA B1

Dermatitis and Pruitus AgentsC1

Ala-Cort

Ala-Cort (1% External Cream) G 2 ¨C1

Alcl

ome

tasone

Dipropio

nate Alclometasone Dipropionate (External Cream) G 3

C1

Alcl

ometaso

ne

Dipropio

nate Alclometasone Dipropionate (External Ointment) G 3

C1

Am

monium

Lactate Ammonium Lactate (External Cream) G 3

C1

Ammon

ium

Lactate Ammonium Lactate (External Lotion) G 3

C1

Betamet

hasone

Dipropio

nate

Aug Betamethasone Dipropionate Aug (External Cream) G 3

C1

Beta

methas

one

Dipropio

nate Aug Betamethasone Dipropionate Aug (External Gel) G 3

C1

Beta

methas

one Dipr

opio

nate Aug Betamethasone Dipropionate Aug (External Lotion) G 3

C1

Betamet

has

one Dipr

opionate

Aug Betamethasone Dipropionate Aug (External Ointment) G 3

C1

Betamet

hasone

Dipr

opionate Betamethasone Dipropionate (External Cream) G 3

C1

Beta

met

hasone

Dipropio

nate Betamethasone Dipropionate (External Lotion) G 3

C1

Beta

methas

one

Dipropio

nate Betamethasone Dipropionate (External Ointment) G 3

C1

Beta

methas

one Vale

rate Betamethasone Valerate (External Cream) G 3

C1

Betamet

hasone

Vale

rate Betamethasone Valerate (External Lotion) G 3

C1

Beta

met

hasone

Valerate Betamethasone Valerate (External Ointment) G 3

C1

Clo

betasol

Pro

pionate

Emollient

Base

Clobetasol Propionate Emollient Base (External Cream) G 4

C1

Clo

betasol

Propion

ate Clobetasol Propionate (External Cream) G 4

C1

Clobeta

sol

Propion

ate Clobetasol Propionate (External Gel) G 4

C1

Clobeta

sol Pro

pion

ate Clobetasol Propionate (External Ointment) G 4

C1

Clo

beta

sol Pro

pionate Clobetasol Propionate (External Shampoo) G 4

C1

Clo

betasol

Propion

ate Clobetasol Propionate (External Solution) G 3

C1

Cordran

Cordran (External Tape) B 4

C1

Desonid

e

Desonide (External Ointment) G 4

C1

Des

oxi

metaso

ne Desoximetasone (External Cream) G 4 QL C1

Dox

epin HCl

Doxepin HCl (External Cream) G 5 PA; DL; QL C1

Fluo

cinolone

Acet

onid

e Fluocinolone Acetonide (External Cream) G 3

C1

Fluocino

lone

Acet

onide Fluocinolone Acetonide (External Ointment) G 3

C1

Fluocino

lone

Acetonid

e Fluocinolone Acetonide (External Solution) G 3

C1

Fluo

cinolone

Acetonid

e Scal

p Fluocinolone Acetonide Scalp (External Oil) G 4




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Fluocino

nide

Emu

lsified

Base Fluocinonide Emulsified Base (External Cream) G 3

C1

Fluocino

nide

Fluocinonide (External Gel) G 3

C1

Fluo

cino

nide

Fluocinonide (External Ointment) G 3

C1

Fluo

cinonide

Fluocinonide (External Solution) G 3

C1

Fluticas

one

Propion

ate Fluticasone Propionate (External Cream) G 3

C1

Fluticas

one Pro

pion

ate Fluticasone Propionate (External Ointment) G 3

C1

Halo

beta

sol Pro

pionate Halobetasol Propionate (External Cream) G 4

C1

Halo

betasol

Pro

pionate Halobetasol Propionate (External Ointment) G 4

C1

Hyd

rocortiso

ne Buty

rate Hydrocortisone Butyrate (External Ointment) G 3

C1

Hydroco

rtiso

ne

Hydrocortisone (1% External Cream, 2.5% External

Cream)G 2 ¨

C1

Hydroco

rtisone

Hydrocortisone (2.5% External Lotion) G 3

C1

Hyd

rocortiso

ne

Hydrocortisone (1% External Ointment, 2.5% External Ointment)

G 2 ¨C1

Hyd

rocortiso

ne Vale

rate Hydrocortisone Valerate (External Cream) G 4

C1

Hydroco

rtiso

ne Vale

rate Hydrocortisone Valerate (External Ointment) G 4

C1

Momet

asone

Furo

ate Mometasone Furoate (External Cream) G 2 ¨C1

Mo

met

asone

Furoate Mometasone Furoate (External Ointment) G 2 ¨C1

Mo

metaso

ne

Furoate Mometasone Furoate (External Solution) G 2 ¨C1

Pim

ecrolimu

s

Pimecrolimus (External Cream) G 4 ST; QL C1

Prednic

arbate

Prednicarbate (External Cream) G 4

C1

Pre

dnic

arbate

Prednicarbate (External Ointment) G 4

C1

Sele

nium

Sulfi

de Selenium Sulfide (External Lotion) G 2 ¨C1

Tacr

olimus

Tacrolimus (External Ointment) G 4 ST C1

Triamci

nolo

ne Acet

onide Triamcinolone Acetonide (External Cream) G 2 ¨C1

Triamci

nolone

Acet

onide Triamcinolone Acetonide (External Lotion) G 2 ¨C1

Tria

mci

nolone

Acetonid

e Triamcinolone Acetonide (0.025% External Ointment,

0.1% External Ointment, 0.5% External Ointment)G 2 ¨

C1

Trid

erm

Triderm (0.1% External Cream) G 2 ¨B1

Dermatological Agents, OtherC1

Calcipotr

iene

Calcipotriene (External Cream) G 4

C1

Calc

ipotr

iene

Calcipotriene (External Ointment) G 4

C1

Calc

ipotriene

Calcipotriene (External Solution) G 3

C1

Calc

itriol

Calcitriol (External Ointment) B 4

C1

Clotrima

zole-

Betamet

hasone Clotrimazole-Betamethasone (External Cream) G 3

C1

Clotrima

zole-Beta

methas

one Clotrimazole-Betamethasone (External Lotion) G 4

C1

Cort

isporin

Cortisporin (External Cream) B 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Cortispo

rin

Cortisporin (External Ointment) B 4

C1

Diclofen

ac Sodi

um Diclofenac Sodium (3% Transdermal Gel) G 4 PA C1

Fluo

rour

acil

Fluorouracil (5% External Cream) G 4

C1

Fluo

rouracil

Fluorouracil (External Solution) G 3

C1

Imiquim

od

Imiquimod (5% External Cream) G 4 QL C1

Imiquim

od Pum

p Imiquimod Pump (3.75% External Cream) B 5 PA; DL C1

Met

hox

salen

Rapid Methoxsalen Rapid (Oral Capsule) G 5 DL C1

Pica

to

Picato (External Gel) B 3 QL C1

Pod

ofilox

Podofilox (External Solution) G 3

C1

Regrane

x

Regranex (External Gel) B 5 PA; DL C1

Santyl

Santyl (External Ointment) B 4

C1

Silv

er Sulf

adia

zine Silver Sulfadiazine (External Cream) G 3

C1

SSD

SSD (External Cream) B 3

C1

Zyclara

Pum

p

Zyclara Pump (External Cream) B 5 PA; DL B1

Pediculicides/ScabicidesC1

Mal

athi

on

Malathion (External Lotion) G 4

C1

Per

methrin

Permethrin (External Cream) G 3

B1

Topical Anti-infectivesC1

Ciclopir

ox

Ciclopirox (External Gel) G 3

C1

Cicl

opir

ox

Ciclopirox (External Shampoo) G 3

C1

Cicl

opirox

Ciclopirox (External Solution) G 3

C1

Cicl

opirox

Olamin

e Ciclopirox Olamine (External Cream) G 3

C1

Ciclopir

ox

Olamin

e Ciclopirox Olamine (External Suspension) G 3

C1

Clindaci

n-P

Clindacin-P (External Swab) G 3

C1

Clin

dam

ycin Pho

sphate Clindamycin Phosphate (External Gel) G 3 QL C1

Clin

damycin

Phosph

ate Clindamycin Phosphate (External Lotion) G 3

C1

Clindam

ycin

Phosph

ate Clindamycin Phosphate (External Solution) G 3

C1

Clindam

ycin Pho

sph

ate Clindamycin Phosphate (External Swab) G 3

C1

Clot

rima

zole

Clotrimazole (External Cream) G 2 ¨C1

Clot

rimazole

Clotrimazole (External Solution) G 2 ¨C1

Eco

nazole

Nitrate Econazole Nitrate (External Cream) G 4 QL C1

Ery

Ery (External Pad) G 3

C1

Erythro

mycin

Erythromycin (External Gel) G 4

C1

Eryt

hromyci

n

Erythromycin (External Solution) G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Gentami

cin

Sulfate Gentamicin Sulfate (External Cream) G 2 ¨C1

Gentami

cin Sulf

ate Gentamicin Sulfate (External Ointment) G 2 ¨C1

Jubli

a

Jublia (External Solution) B 4

C1

Ket

oconaz

ole

Ketoconazole (External Cream) G 2 QL ¨C1

Ketoco

naz

ole

Ketoconazole (External Shampoo) G 2 ¨C1

Mentax

Mentax (External Cream) B 4

C1

Mup

iroci

n Calc

ium Mupirocin Calcium (External Cream) G 4

C1

Mup

irocin

Mupirocin (External Ointment) G 2 QL ¨C1

Nafti

fine HCl

Naftifine HCl (External Cream) G 4

C1

Naftin

Naftin (2% External Gel) B 4

C1

Nyamyc

Nyamyc (External Powder) G 2 QL ¨C1

Nyst

atin

Nystatin (External Cream) G 2 ¨C1

Nyst

atin

Nystatin (External Ointment) G 2 ¨C1

Nystatin

Nystatin (External Powder) G 2 QL ¨C1

Nystop

Nystop (External Powder) G 2 QL ¨C1

Sulf

amyl

on

Sulfamylon (External Cream) B 4

A1

Electrolytes/Minerals/Metals/VitaminsB1

Electrolyte/Mineral ReplacementC1

Aminos

yn II

Aminosyn II (Intravenous Solution) B 4 B/D, PA C1

Ami

nos

yn-PF

Aminosyn-PF (7% Intravenous Solution) B 4 B/D, PA C1

Car

baglu

Carbaglu (Oral Tablet) B 5 LA; DL C1

Dext

rose

Dextrose (10% Intravenous Solution) G 4

C1

Dextrose

Dextrose (5% Intravenous Solution) G 4 B/D, PA C1

Dextrose

-NaC

l Dextrose-NaCl (10-0.2% Intravenous Solution,

10-0.45% Intravenous Solution, 2.5-0.45%

Intravenous Solution, 5-0.2% Intravenous Solution,

5-0.225% Intravenous Solution, 5-0.45% Intravenous

Solution)

B 4

C1

Dext

rose

-NaC

l Dextrose-NaCl (5-0.9% Intravenous Solution) B 4 B/D, PA C1

Fre

Amine

HBC

FreAmine HBC (Intravenous Solution) B 4 B/D, PA C1

HepatA

min

e

HepatAmine (Intravenous Solution) B 4 B/D, PA C1

Intralipid

Intralipid (Intravenous Emulsion) B 4 B/D, PA C1

Isoly

te-P

in D5

W Isolyte-P in D5W (Intravenous Solution) B 4

C1

Isoly

te-S

Isolyte-S (Intravenous Solution) B 4

C1

KCl

in Dext

rose-

NaC

l KCl in Dextrose-NaCl (Intravenous Solution) B 4

C1

KCl-Lact

ated

Ring

ers-D5

W KCl-Lactated Ringers-D5W (Intravenous Solution) B 4

C1

Klor-Con

10

Klor-Con 10 (Oral Tablet Extended Release) B 2 ¨


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Klor-Con

M10

Klor-Con M10 (Oral Tablet Extended Release) G 2 ¨C1

Klor-Con

M15


Klor-

Con

M20


Klor-

Con

Klor-Con (Oral Packet) G 3

C1

Klor-Con

8

Klor-Con 8 (Oral Tablet Extended Release) B 2 ¨C1

Magnesi

um Sulf

ate Magnesium Sulfate (50% Injection Solution) B 4

C1

Mag

nesi

um Sulf

ate Magnesium Sulfate (50% (10ML Syringe) Injection

Solution)G 4

C1

Nep

hrAmin

e

NephrAmine (Intravenous Solution) B 4 B/D, PA C1

Nor

mosol-M

in D5

W Normosol-M in D5W (Intravenous Solution) B 4

C1

Normos

ol-R

Normosol-R (Intravenous Solution) B 4

C1

Nutrilipid

Nutrilipid (Intravenous Emulsion) B 4 B/D, PA C1

Plas

ma-Lyte

148

Plasma-Lyte 148 (Intravenous Solution) B 4

C1

Plas

ma-Lyte

A

Plasma-Lyte A (Intravenous Solution) B 4

C1

Plenami

ne

Plenamine (Intravenous Solution) G 4 B/D, PA C1

Potassiu

m Chlo

ride

CR Potassium Chloride CR (Oral Tablet Extended Release) G 2 ¨C1

Pota

ssiu

m Chlo

ride ER Potassium Chloride ER (Oral Capsule Extended

Release)G 2 ¨

C1

Pota

ssium

Chlo

ride in

Dextrose Potassium Chloride in Dextrose (20MEQ/L

Intravenous Solution)B 4 B/D, PA

C1

Pota

ssium

Chloride

in NaC

l Potassium Chloride in NaCl (20-0.45MEQ/L-% Intravenous Solution)

G 4 B/D, PA C1

Potassiu

m Chlo

ride

in NaC

l Potassium Chloride in NaCl (20-0.9MEQ/L-%

Intravenous Solution, 40-0.9MEQ/L-% Intravenous

Solution)

B 4 B/D, PA

C1

Pota

ssiu

m Chlo

ride Potassium Chloride (10MEQ/100ML Intravenous

Solution, 20MEQ/100ML Intravenous Solution,

40MEQ/100ML Intravenous Solution)

B 4 B/D, PA

C1

Pota

ssium

Chlo

ride Potassium Chloride (2MEQ/ML Intravenous Solution,

2MEQ/ML (20ML) Intravenous Solution)G 4 B/D, PA

C1

Pota

ssium

Chloride Potassium Chloride (Oral Packet) G 3

C1

Potassiu

m

Chloride Potassium Chloride (Oral Solution) G 3

C1

Potassiu

m Citra

te

ER Potassium Citrate ER (Oral Tablet Extended Release) G 3

C1

Pre

mas

ol

Premasol (Intravenous Solution) G 4 B/D, PA C1

Proc

alamin

e

Procalamine (Intravenous Solution) B 4 B/D, PA




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Prosol

Prosol (Intravenous Solution) B 4 B/D, PA C1

Sodium

Chloride

Sodium Chloride (0.45% Intravenous Solution) G 4

C1

Sodi

um

Chloride

Sodium Chloride (0.9% Intravenous Solution, 3%

Intravenous Solution)G 4 B/D, PA

C1

Sodi

um Chlo

ride

Sodium Chloride (5% Intravenous Solution) B 4 B/D, PA C1

Sodium

Chlo

ride

Sodium Chloride (Irrigation Solution) B 3

C1

Sodium

Fluoride

Sodium Fluoride (Oral Tablet) G 2 ¨C1

TPN

Elec

trolytes

TPN Electrolytes (Intravenous Concentrate) B 4

C1

Trav

asol

Travasol (Intravenous Solution) B 4 B/D, PA C1

Tro

phAmin

e

TrophAmine (10% Intravenous Solution) B 4 B/D, PA B1

Electrolyte/Mineral/Metal ModifiersC1

Chemet

Chemet (Oral Capsule) B 5 DL C1

Clov

ique

Clovique (Oral Capsule) G 5 PA; DL; QL C1

Def

erasirox

Deferasirox (Oral Tablet) (Generic Jadenu) G 5 PA; DL C1

Deferas

irox

Deferasirox (Oral Tablet Soluble) (Generic Exjade) G 5 PA; DL C1

Ferriprox

Ferriprox (Oral Solution) B 5 PA; DL C1

Ferri

prox

Ferriprox (Oral Tablet) B 5 PA; DL C1

Jad

enu Spri

nkle

Jadenu Sprinkle (Oral Packet) B 5 PA; DL C1

Trie

ntine

HCl

Trientine HCl (Oral Capsule) G 5 PA; DL; QL B1

Phosphate BindersC1

Aury

xia

Auryxia (Oral Tablet) B 5 PA; DL C1

Calc

ium Acet

ate

Calcium Acetate (Phosphate Binder) (Oral Capsule) G 3

C1

Calc

ium Acet

ate

Calcium Acetate (Phosphate Binder) (Oral Tablet) G 3

C1

Lanthan

um

Carbon

ate Lanthanum Carbonate (Oral Tablet Chewable) G 5 DL C1

Phoslyra

Phoslyra (Oral Solution) B 3

C1

Sev

ela

mer Car

bonate Sevelamer Carbonate (Oral Packet) G 5 DL C1

Sev

elamer

Carbon

ate Sevelamer Carbonate (Oral Tablet) (Generic Renvela) G 4

C1

Velphoro

Velphoro (Oral Tablet Chewable) B 5 DL B1

Potassium BindersC1

Kion

ex

Kionex (Oral Suspension) G 3

C1

Lok

elma

Lokelma (Oral Packet) B 4 QL C1

Sodi

um Poly

styrene

Sulf

onate Sodium Polystyrene Sulfonate (Oral Powder) G 3

C1

Sodium

Poly

styrene

Sulfonat

e Sodium Polystyrene Sulfonate (Oral Suspension) G 3

C1

SPS

SPS (Oral Suspension) G 3

C1

Velt

assa

Veltassa (Oral Packet) B 5 DL; QL B1

VitaminsC1

VP-PNV

-

DHA

VP-PNV-DHA (Oral Capsule) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

A1

Gastrointestinal AgentsB1

Anti-Constipation AgentsC1

Amit

iza

Amitiza (Oral Capsule) B 3 QL C1

Con

stulose

Constulose (Oral Solution) G 2 ¨C1

Enulose

Enulose (Oral Solution) G 2 ¨C1

Generla

c

Generlac (Oral Solution) G 2 ¨C1

Lact

ulos

e

Lactulose (10GM/15ML Oral Solution) G 2 ¨C1

Linz

ess

Linzess (Oral Capsule) B 3 QL C1

Reli

stor

Relistor (Oral Tablet) B 5 PA; DL; QL C1

Relistor

Relistor (Subcutaneous Solution) B 5 PA; DL B1

Anti-Diarrheal AgentsC1

Alos

etron

HCl

Alosetron HCl (Oral Tablet) G 5 PA; DL C1

Diph

enoxylat

e-Atro

pine Diphenoxylate-Atropine (Oral Liquid) G 4

C1

Dipheno

xylat

e-Atro

pine Diphenoxylate-Atropine (Oral Tablet) G 4

C1

Lopera

mide

HCl Loperamide HCl (Oral Capsule) G 2 ¨B1

Antispasmodics, GastrointestinalC1

Cuv

posa

Cuvposa (Oral Solution) B 4 PA C1

Dicy

clomin

e HCl Dicyclomine HCl (Oral Capsule) G 2 ¨C1

Dicyclo

mine

HCl Dicyclomine HCl (Oral Solution) G 2 ¨C1

Dicy

clo

mine

HCl Dicyclomine HCl (Oral Tablet) G 2 ¨C1

Met

hscopol

ami

ne Bro

mide Methscopolamine Bromide (Oral Tablet) G 4

B1

Gastrointestinal Agents, OtherC1

Chenod

al

Chenodal (Oral Tablet) G 5 PA; DL C1

Clenpiq

Clenpiq (Oral Solution) B 3

C1

Gatt

ex

Gattex (Subcutaneous Kit) B 5 PA; LA; DL C1

Gavi

Lyte-C

GaviLyte-C (Oral Solution Reconstituted) G 2 ¨C1

GaviLyte

-G

GaviLyte-G (Oral Solution Reconstituted) G 2 ¨C1

GaviLyte

-N with

Flav

or Pac

k GaviLyte-N with Flavor Pack (Oral Solution Reconstituted)

G 2 ¨C1

Myal

ept

Myalept (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL C1

Ocal

iva

Ocaliva (Oral Tablet) B 5 PA; DL; QL C1

PEG

-3350-

NaCl-Na

Bica

rbonate-

KCl PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution)

(Generic NuLYTELY)G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

PEG-335

0-

Electroly

tes PEG-3350-Electrolytes (Oral Solution) (Generic

GoLYTELY)G 2 ¨

C1

Suprep

Bowel

Prep Kit Suprep Bowel Prep Kit (Oral Solution) B 3

C1

TriL

yte

TriLyte (Oral Solution Reconstituted) G 2 ¨C1

Urs

odiol

Ursodiol (Oral Capsule) G 3

C1

Ursodio

l

Ursodiol (Oral Tablet) G 4

B1

Histamine2 (H2) Receptor AntagonistsC1

Cim

etidi

ne HCl

Cimetidine HCl (Oral Solution) G 3

C1

Cim

etidine

Cimetidine (Oral Tablet) G 3

C1

Fam

otidine

Famotidine (Oral Suspension Reconstituted) G 4

C1

Famotidi

ne

Famotidine (20MG Oral Tablet, 40MG Oral Tablet) G 2 ¨C1

Nizatidin

e

Nizatidine (Oral Capsule) G 3

B1

ProtectantsC1

Mis

oprosto

l

Misoprostol (Oral Tablet) G 3

C1

Sucralfat

e

Sucralfate (Oral Suspension) G 4

C1

Sucralfat

e

Sucralfate (Oral Tablet) G 2 ¨B1

Proton Pump InhibitorsC1

Dexi

lant

Dexilant (Oral Capsule Delayed Release) B 4 QL C1

Eso

meprazo

le Mag

nesium Esomeprazole Magnesium (Oral Capsule Delayed

Release) (Generic Nexium)G 3 QL

C1

Lansopr

azole

Lansoprazole (Oral Capsule Delayed Release) G 2 QL ¨C1

Om

epra

zole

Omeprazole (10MG Oral Capsule Delayed Release) G 2 QL ¨C1

Om

eprazole

Omeprazole (20MG Oral Capsule Delayed Release,

40MG Oral Capsule Delayed Release)G 2 ¨

C1

Pant

oprazole

Sodi

um Pantoprazole Sodium (Oral Tablet Delayed Release) G 1 QL ¨C1

Prilosec

Prilosec (Oral Packet) B 4 PA C1

Rabepra

zole

Sodi

um Rabeprazole Sodium (Oral Tablet Delayed Release) G 3

A1

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, TreatmentB1

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, TreatmentC1

Aralast

NP

Aralast NP (1000MG Intravenous Solution

Reconstituted)B 5 PA; LA; DL

C1

Cholbam

Cholbam (Oral Capsule) B 5 PA; DL C1

Cre

on

Creon (Oral Capsule Delayed Release Particles) B 3

C1

Cro

molyn

Sodi

um Cromolyn Sodium (Oral Concentrate) G 3

C1

Cyst

adane

Cystadane (Oral Powder) B 5 DL C1

Cystago

n

Cystagon (Oral Capsule) B 4 LA C1

Glassia

Glassia (Intravenous Solution) B 5 PA; LA; DL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Kuvan

Kuvan (Oral Packet) B 5 LA; DL C1

Kuvan

Kuvan (Oral Tablet Soluble) B 5 LA; DL C1

Lev

ocar

nitine

Levocarnitine (1GM/10ML Oral Solution) G 3

C1

Lev

ocarnitin

e

Levocarnitine (330MG Oral Tablet) B 3

C1

Miglusta

t

Miglustat (Oral Capsule) G 5 PA; LA; DL C1

Nitisinon

e

Nitisinone (Oral Capsule) G 5 DL C1

Orfa

din

Orfadin (20MG Oral Capsule) B 5 LA; DL C1

Orfa

din

Orfadin (Oral Suspension) B 5 LA; DL C1

Proc

ysbi

Procysbi (Oral Packet) B 5 LA; DL C1

Prolastin

-C

Prolastin-C (Intravenous Solution Reconstituted) B 5 PA; LA; DL C1

RAVICTI

RAVICTI (Oral Liquid) B 5 LA; DL; QL C1

Sodi

um Phe

nylb

utyrate Sodium Phenylbutyrate (Oral Powder) G 5 DL C1

Sodi

um Phe

nylbutyr

ate Sodium Phenylbutyrate (Oral Tablet) G 5 DL C1

Sucraid

Sucraid (Oral Solution) B 5 LA; DL C1

Tegsedi

Tegsedi (Subcutaneous Solution Prefilled Syringe) B 5 PA; LA; DL C1

Vyn

dam

ax

Vyndamax (Oral Capsule) B 5 PA; LA; DL; QL C1

Vyn

daqel

Vyndaqel (Oral Capsule) B 5 PA; LA; DL; QL C1

Zem

aira

Zemaira (Intravenous Solution Reconstituted) B 5 PA; LA; DL C1

Zenpep

Zenpep (Oral Capsule Delayed Release Particles) B 3

A1

Genitourinary AgentsB1

Antispasmodics, UrinaryC1

Myr

betriq

Myrbetriq (Oral Tablet Extended Release 24 Hour) B 3

C1

Oxybuty

nin

Chloride

ER Oxybutynin Chloride ER (Oral Tablet Extended Release 24 Hour)

G 2 QL ¨C1

Oxybuty

nin Chlo

ride Oxybutynin Chloride (Oral Syrup) G 2 ¨C1

Oxy

buty

nin Chlo

ride Oxybutynin Chloride (Oral Tablet Immediate Release) G 2 ¨C1

Solif

enacin

Succina

te Solifenacin Succinate (Oral Tablet) G 3 QL C1

Tolterod

ine

Tartrate

ER Tolterodine Tartrate ER (Oral Capsule Extended Release 24 Hour)

G 4

B1

Benign Prostatic Hypertrophy AgentsC1

Alfu

zosi

n HCl

ER Alfuzosin HCl ER (Oral Tablet Extended Release 24

Hour)G 2 ¨

C1

Duta

steride

Dutasteride (Oral Capsule) G 3 QL C1

Fina

steride

Finasteride (5MG Oral Tablet) (Generic Proscar) G 1 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Silodosi

n

Silodosin (Oral Capsule) G 3 QL C1

Tamsulo

sin HCl

Tamsulosin HCl (Oral Capsule) G 1 ¨C1

Tera

zosi

n HCl

Terazosin HCl (Oral Capsule) G 2 ¨B1

Genitourinary Agents, OtherC1

Bethane

chol

Chlo

ride Bethanechol Chloride (Oral Tablet) G 2 ¨C1

Depen

Titratabs

Depen Titratabs (Oral Tablet) B 5 DL C1

Elmi

ron

Elmiron (Oral Capsule) B 5 DL C1

Lith

ostat

Lithostat (Oral Tablet) B 5 DL C1

Peni

cillamin

e

Penicillamine (250MG Oral Capsule) G 5 PA; DL C1

Penicilla

min

e

Penicillamine (250MG Oral Tablet) G 5 DL A1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)C1

Cort

isone

Acetate Cortisone Acetate (Oral Tablet) G 4

C1

Dexame

thas

one Inte

nsol Dexamethasone Intensol (Oral Concentrate) G 2 ¨C1

Dexame

thasone

Dexamethasone (Oral Elixir) G 2 ¨C1

Dex

ame

thasone

Dexamethasone (Oral Tablet) G 2 ¨C1

Flud

rocortiso

ne

Acetate Fludrocortisone Acetate (Oral Tablet) G 2 ¨C1

Hyd

rocortiso

ne

Hydrocortisone (Oral Tablet) G 3

C1

Methylp

rednisol

one Methylprednisolone (Oral Tablet) G 2 ¨C1

Met

hylp

rednisol

one Methylprednisolone (Oral Tablet Therapy Pack) G 2 ¨C1

Pre

dnisolon

e

Prednisolone (Oral Solution) G 2 ¨C1

Pre

dnisolon

e Sodi

um

Phosph

ate Prednisolone Sodium Phosphate (25MG/5ML Oral

Solution, 6.7MG/5ML Oral Solution)G 2 ¨

C1

Prednis

one

Intensol Prednisone Intensol (Oral Concentrate) G 2 ¨C1

Prednis

one

Prednisone (5MG/5ML Oral Solution) G 2 ¨C1

Pre

dnis

one

Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG

Oral Tablet)

G 1 ¨

C1

Pre

dnisone

Prednisone (10MG (21) Oral Tablet Therapy Pack, 10MG

(48) Oral Tablet Therapy Pack, 5MG (21) Oral Tablet

Therapy Pack, 5MG (48) Oral Tablet Therapy Pack)

G 1 ¨

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)C1

Des

mop

ressin

Acetate Desmopressin Acetate (Oral Tablet) G 3

C1

Des

mopressi

n

Acetate

Spray Desmopressin Acetate Spray (Nasal Solution) G 4

C1

Egrif

ta

Egrifta (1MG Subcutaneous Solution Reconstituted) B 5 PA; LA; DL C1

Egrifta

SV

Egrifta SV (2MG Subcutaneous Solution

Reconstituted)B 5 PA; LA; DL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Genotro

pin

MiniQuic

k Genotropin MiniQuick (Subcutaneous Solution

Reconstituted)B 5 PA; DL

C1

Genotro

pin

Genotropin (Subcutaneous Solution Reconstituted) B 5 PA; DL C1

Incr

elex

Increlex (Subcutaneous Solution) B 5 PA; LA; DL C1

Ser

ostim

Serostim (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL C1

Zorbtiv

e

Zorbtive (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL A1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)C1

Korl

ym

Korlym (Oral Tablet) B 5 PA; LA; DL; QL A1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)B1

Anabolic SteroidsC1

Anadrol-

50

Anadrol-50 (Oral Tablet) B 5 PA; DL C1

Oxa

ndrolone

Oxandrolone (10MG Oral Tablet) G 4 PA; QL C1

Oxa

ndrolone

Oxandrolone (2.5MG Oral Tablet) G 3 PA; QL B1

AndrogensC1

Androde

rm

Androderm (Transdermal Patch 24 Hour) B 3 QL C1

Dan

azol

Danazol (Oral Capsule) G 4

C1

Test

osterone

Cypionat

e Testosterone Cypionate (Intramuscular Solution) G 2 ¨C1

Test

osterone

Ena

nthate Testosterone Enanthate (Intramuscular Solution) G 3

C1

Testoste

rone

Testosterone (25MG/2.5GM 1% Transdermal Gel,

50MG/5GM 1% Transdermal Gel), Testosterone Pump (1% Transdermal Gel)

G 3

C1

Test

oste

rone

Testosterone (20.25MG/1.25GM 1.62% Transdermal Gel, 40.5MG/2.5GM 1.62% Transdermal Gel),

Testosterone Pump (1.62% Transdermal Gel)

G 4

B1

EstrogensC1

Alta

vera

Altavera (Oral Tablet) G 4

C1

Alyacen

1/35

Alyacen 1/35 (Oral Tablet) G 4

C1

Amethia

Amethia (Oral Tablet) G 4

C1

Apri

Apri (Oral Tablet) G 4

C1

Aran

elle

Aranelle (Oral Tablet) G 4

C1

Ashlyna

Ashlyna (Oral Tablet) G 4

C1

Aubra

EQ

Aubra EQ (Oral Tablet) G 4

C1

Avia

ne

Aviane (Oral Tablet) G 4

C1

Balz

iva

Balziva (Oral Tablet) G 4




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Blisovi

24

Fe

Blisovi 24 Fe (Oral Tablet) G 4

C1

Blisovi

Fe 1.5/

30 Blisovi Fe 1.5/30 (Oral Tablet) G 4

C1

Briel

lyn

Briellyn (Oral Tablet) G 4

C1

Cam

rese Lo

Camrese Lo (Oral Tablet) G 4

C1

Caziant

Caziant (Oral Tablet) G 4

C1

Climara

Pro

Climara Pro (Transdermal Patch Weekly) B 4

C1

Crys

elle-

28

Cryselle-28 (Oral Tablet) G 4

C1

Cycl

afem

1/35

Cyclafem 1/35 (Oral Tablet) G 4

C1

Cycl

afem

7/7/7 Cyclafem 7/7/7 (Oral Tablet) G 4

C1

Cyred

EQ

Cyred EQ (Oral Tablet) G 4

C1

Depo-

Estradio

l Depo-Estradiol (Intramuscular Oil) G 4

C1

Des

ogestrel

-

Ethinyl

Estradio

l Desogestrel-Ethinyl Estradiol (Oral Tablet) G 4

C1

Dro

spireno

ne-Ethi

nyl

Estradio

l Drospirenone-Ethinyl Estradiol (Oral Tablet) G 4

C1

Duavee

Duavee (Oral Tablet) B 4

C1

Elestrin

Elestrin (Transdermal Gel) B 4

C1

Elu

Ryn

g

EluRyng (Vaginal Ring) G 4

C1

Emo

quette

Emoquette (Oral Tablet) G 4

C1

Enp

resse-28

Enpresse-28 (Oral Tablet) G 4

C1

Enskyce

Enskyce (Oral Tablet) G 4

C1

Esta

rylla

Estarylla (Oral Tablet) G 4

C1

Estr

adiol

Estradiol (Oral Tablet) G 2 ¨C1

Estr

adiol

Estradiol (Transdermal Patch Weekly) G 3 QL C1

Estradio

l

Estradiol (Vaginal Cream) G 4

C1

Estradio

l

Estradiol (Vaginal Tablet) G 4 QL C1

Estr

adio

l Vale

rate Estradiol Valerate (Intramuscular Oil) G 4

C1

Estri

ng

Estring (Vaginal Ring) B 4

C1

Ethynodi

ol

Diacetat

e-Ethi

nyl

Estradio

l

Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet) G 4

C1

Etonoge

strel-

Ethi

nyl Estr

adiol Etonogestrel-Ethinyl Estradiol (Vaginal Ring) G 4

C1

Fal

min

a

Falmina (Oral Tablet) G 4

C1

Fay

osim

Fayosim (Oral Tablet) G 4

C1

Fem

ring

Femring (Vaginal Ring) B 4

C1

Femynor

Femynor (Oral Tablet) G 4

C1

Fyavolv

Fyavolv (Oral Tablet) G 4

C1

Gian

vi

Gianvi (Oral Tablet) G 4

C1

Hail

ey 24

Fe

Hailey 24 Fe (Oral Tablet) G 4

C1

Imvexxy

Mainten

ance

Pac

k Imvexxy Maintenance Pack (Vaginal Insert) B 3 PA; QL C1

Imvexxy

Start

er

Pack Imvexxy Starter Pack (Vaginal Insert) B 3 PA; QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Introvale

Introvale (Oral Tablet) G 4

C1

Isibloom

Isibloom (Oral Tablet) G 4

C1

Jas

miel

Jasmiel (Oral Tablet) G 4

C1

Jint

eli

Jinteli (Oral Tablet) G 4

C1

Juleber

Juleber (Oral Tablet) G 4

C1

Junel

1.5/30

Junel 1.5/30 (Oral Tablet) G 4

C1

Jun

el

1/20

Junel 1/20 (Oral Tablet) G 4

C1

Jun

el Fe

1.5/

30 Junel Fe 1.5/30 (Oral Tablet) G 4

C1

Jun

el Fe

1/20

Junel Fe 1/20 (Oral Tablet) G 4

C1

Junel

Fe

24

Junel Fe 24 (Oral Tablet) G 4

C1

Kaitlib

Fe

Kaitlib Fe (Oral Tablet Chewable) G 4

C1

Kari

va

Kariva (Oral Tablet) G 4

C1

Keln

or 1/35

Kelnor 1/35 (Oral Tablet) G 4

C1

Kelnor

1/50

Kelnor 1/50 (Oral Tablet) G 4

C1

Kurvelo

Kurvelo (Oral Tablet) G 4

C1

LAR

IN

1.5/30

LARIN 1.5/30 (Oral Tablet) G 4

C1

LAR

IN 1/20

LARIN 1/20 (Oral Tablet) G 4

C1

LAR

IN Fe

1.5/30 LARIN Fe 1.5/30 (Oral Tablet) G 4

C1

LARIN

Fe 1/20

LARIN Fe 1/20 (Oral Tablet) G 4

C1

Lari

ssia

Larissia (Oral Tablet) G 4

C1

Lay

olis Fe

Layolis Fe (Oral Tablet Chewable) B 4

C1

Lee

na

Leena (Oral Tablet) G 4

C1

Lessina

Lessina (Oral Tablet) G 4

C1

Levone

st

Levonest (Oral Tablet) G 4

C1

Lev

onor

gestrel-

Ethinyl

Estradio

l &

Ethinyl

Estradio

l

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral

Tablet)G 4

C1

Lev

onorgest

rel-Ethi

nyl

Estradio

l 91-Day

Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet) G 4

C1

Levonor

gest

rel-Ethi

nyl Estr

adio

l Levonorgestrel-Ethinyl Estradiol (Oral Tablet) G 4

C1

Levora

0.15/30

Levora 0.15/30 (28) (Oral Tablet) G 4

C1

Lory

na

Loryna (Oral Tablet) G 4

C1

Low

-Oge

strel

Low-Ogestrel (Oral Tablet) G 4

C1

Lute

ra

Lutera (Oral Tablet) G 4

C1

Marlissa

Marlissa (Oral Tablet) G 4

C1

Melodet

ta 24

Fe Melodetta 24 Fe (Oral Tablet Chewable) G 4




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Menest

Menest (Oral Tablet) G 3

C1

Mibelas

24 Fe

Mibelas 24 Fe (Oral Tablet Chewable) G 4

C1

Micr

oge

stin 1.5/

30 Microgestin 1.5/30 (Oral Tablet) G 4

C1

Micr

ogestin

1/20

Microgestin 1/20 (Oral Tablet) G 4

C1

Microge

stin

Fe 1.5/

30 Microgestin Fe 1.5/30 (Oral Tablet) G 4

C1

Microge

stin Fe

1/20 Microgestin Fe 1/20 (Oral Tablet) G 4

C1

Mili

Mili (Oral Tablet) G 4

C1

Nec

on 0.5/

35

Necon 0.5/35 (28) (Oral Tablet) G 4

C1

Nikk

i

Nikki (Oral Tablet) G 4

C1

Norethi

ndro

ne Acet

ate-Ethi

nyl Estr

adio

l

Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG

Oral Tablet, 1-20MG-MCG Oral Tablet, 1-5MG-MCG Oral

Tablet)

G 4

C1

Norethi

ndrone

Acetate-

Ethi

nyl Estr

adiol-Fe

Norethindrone Acetate-Ethinyl Estradiol-Fe (0.4-35MG-

MCG Oral Tablet Chewable, 0.8-25MG-MCG Oral Tablet

Chewable, 1-20MG-MCG(24) Oral Tablet Chewable)

G 4

C1

Nor

gestimat

e-

Ethinyl

Estradio

l Norgestimate-Ethinyl Estradiol (Oral Tablet) G 4

C1

Nor

gestimat

e-Ethi

nyl

Estradio

l Trip

hasi

c

Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet) G 4

C1

Nortrel

0.5/

35

Nortrel 0.5/35 (28) (Oral Tablet) G 4

C1

Nortrel

1/35

Nortrel 1/35 (21) (Oral Tablet) G 4

C1

Nort

rel

1/35

Nortrel 1/35 (28) (Oral Tablet) G 4

C1

Nort

rel 7/7/

7

Nortrel 7/7/7 (Oral Tablet) G 4

C1

Ocel

la

Ocella (Oral Tablet) G 4

C1

Orsythia

Orsythia (Oral Tablet) G 4

C1

Pimt

rea

Pimtrea (Oral Tablet) G 4

C1

Pirm

ella 1/35

Pirmella 1/35 (Oral Tablet) G 4

C1

Porti

a-28

Portia-28 (Oral Tablet) G 4

C1

Premari

n

Premarin (Oral Tablet) B 4 QL C1

Premari

n

Premarin (Vaginal Cream) B 3

C1

Pre

mph

ase

Premphase (Oral Tablet) B 4 QL C1

Pre

mpro

Prempro (Oral Tablet) B 4 QL C1

Previfem

Previfem (Oral Tablet) G 4

C1

Reclipse

n

Reclipsen (Oral Tablet) G 4

C1

Rive

lsa

Rivelsa (Oral Tablet) G 4

C1

Setl

akin

Setlakin (Oral Tablet) G 4

C1

Spri

ntec 28

Sprintec 28 (Oral Tablet) G 4

C1

Sronyx

Sronyx (Oral Tablet) G 4

C1

Syeda

Syeda (Oral Tablet) G 4

C1

Tari

na 24

Fe

Tarina 24 Fe (Oral Tablet) G 4


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Tarina

Fe

1/20 EQ Tarina Fe 1/20 EQ (Oral Tablet) G 4

C1

Tri-Esta

rylla

Tri-Estarylla (Oral Tablet) G 4

C1

Tri-

Leg

est Fe

Tri-Legest Fe (Oral Tablet) G 4

C1

Tri-

Lo-Esta

rylla

Tri-Lo-Estarylla (Oral Tablet) G 4

C1

Tri-Lo-

Spri

ntec

Tri-Lo-Sprintec (Oral Tablet) G 4

C1

Tri-Mili

Tri-Mili (Oral Tablet) G 4

C1

Tri-

Prev

ifem

Tri-Previfem (Oral Tablet) G 4

C1

Tri-

Sprintec

Tri-Sprintec (Oral Tablet) G 4

C1

Triv

ora

Trivora (28) (Oral Tablet) G 4

C1

Tri-VyLi

bra

Lo

Tri-VyLibra Lo (Oral Tablet) G 4

C1

Tri-VyLi

bra

Tri-VyLibra (Oral Tablet) G 4

C1

Veli

vet

Velivet (Oral Tablet) G 4

C1

Vien

va

Vienva (Oral Tablet) G 4

C1

Vyfemla

Vyfemla (Oral Tablet) G 4

C1

VyLibra

VyLibra (Oral Tablet) G 4

C1

WY

MZ

YA Fe

WYMZYA Fe (Oral Tablet Chewable) G 4

C1

Xula

ne

Xulane (Transdermal Patch Weekly) G 4

C1

Yuv

afem

Yuvafem (Vaginal Tablet) G 4 QL C1

Zarah

Zarah (Oral Tablet) G 4

C1

Zovi

a

1/35E

Zovia 1/35E (28) (Oral Tablet) G 4

B1

ProgestinsC1

Cam

ila

Camila (Oral Tablet) G 4

C1

Crinone

Crinone (Vaginal Gel) B 4 PA C1

Deblitan

e

Deblitane (Oral Tablet) G 4

C1

Dep

o-

Provera

Depo-Provera (400MG/ML Intramuscular Suspension) B 4

C1

Errin

Errin (Oral Tablet) G 4

C1

Incassia

Incassia (Oral Tablet) G 4

C1

Lyza

Lyza (Oral Tablet) G 4

C1

Med

roxy

progest

erone

Acet

ate Medroxyprogesterone Acetate (150MG/ML

Intramuscular Suspension)G 4

C1

Med

roxypro

gest

erone

Acetate Medroxyprogesterone Acetate (150MG/ML

Intramuscular Suspension Prefilled Syringe)G 4

C1

Med

roxypro

gesteron

e

Acetate Medroxyprogesterone Acetate (10MG Oral Tablet,

2.5MG Oral Tablet, 5MG Oral Tablet)G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Megestr

ol

Acetate Megestrol Acetate (40MG/ML Oral Suspension) G 3

C1

Megestr

ol Acet

ate Megestrol Acetate (625MG/5ML Oral Suspension) G 4

C1

Meg

estr

ol Acet

ate Megestrol Acetate (Oral Tablet) G 3

C1

Nor

a-BE

Nora-BE (Oral Tablet) G 4

C1

Norethi

ndro

ne Acet

ate Norethindrone Acetate (5MG Oral Tablet) G 2 ¨C1

Norethi

ndrone

Norethindrone (0.35MG Oral Tablet) G 4

C1

Pro

gest

erone

Microniz

ed Progesterone Micronized (Oral Capsule) G 2 ¨C1

Shar

obel

Sharobel (Oral Tablet) G 4

B1

Selective Estrogen Receptor Modifying AgentsC1

Osphen

a

Osphena (Oral Tablet) B 3 PA; QL C1

Raloxife

ne HCl

Raloxifene HCl (Oral Tablet) G 3 QL A1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)B1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)C1

Euthyrox

Euthyrox (Oral Tablet) B 3

C1

Levo-T

Levo-T (Oral Tablet) B 3

C1

Lev

othy

roxine

Sodium Levothyroxine Sodium (Oral Tablet) G 1 ¨C1

Lev

oxyl

Levoxyl (Oral Tablet) B 3

C1

Liot

hyronine

Sodi

um Liothyronine Sodium (Oral Tablet) G 2 ¨C1

Synthroi

d

Synthroid (Oral Tablet) B 3

C1

Unit

hroi

d

Unithroid (100MCG Oral Tablet, 112MCG Oral Tablet,

125MCG Oral Tablet, 150MCG Oral Tablet, 175MCG

Oral Tablet, 200MCG Oral Tablet, 25MCG Oral Tablet,

300MCG Oral Tablet, 50MCG Oral Tablet, 75MCG

Oral Tablet, 88MCG Oral Tablet)

B 3

A1

Hormonal Agents, Suppressant (Adrenal)B1

Hormonal Agents, Suppressant (Adrenal)C1

Lysodre

n

Lysodren (Oral Tablet) B 5 DL A1

Hormonal Agents, Suppressant (Pituitary)B1

Hormonal Agents, Suppressant (Pituitary)C1

Cab

ergoline

Cabergoline (Oral Tablet) G 3

C1

Firmago

n

Firmagon (240MG Dose) (120MG/Vial Subcutaneous

Solution Reconstituted)B 5 PA; DL

C1

Firmago

n

Firmagon (80MG Subcutaneous Solution

Reconstituted)B 4 PA

C1

Leu

proli

de Acet

ate Leuprolide Acetate (Injection Kit) G 4 PA C1

Lup

aneta

Pac

k Lupaneta Pack (Combination Kit) B 5 PA; DL C1

Lupr

on Dep

ot

Lupron Depot (1-Month) (Intramuscular Kit) B 5 PA; DL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lupron

Dep

ot

Lupron Depot (3-Month) (Intramuscular Kit) B 5 PA; DL C1

Lupron

Depot


Lupr

on

Depot


Octr

eotide

Acetate Octreotide Acetate (1000MCG/ML Injection Solution,

500MCG/ML Injection Solution)G 5 PA; DL

C1

Octreoti

de

Acetate Octreotide Acetate (100MCG/ML Injection Solution,

200MCG/ML Injection Solution, 50MCG/ML Injection

Solution)

G 4 PA

C1

Signifor

Signifor (Subcutaneous Solution) B 5 PA; LA; DL C1

Som

atuli

ne Dep

ot Somatuline Depot (Subcutaneous Solution) B 5 DL C1

Som

avert

Somavert (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL; QL C1

Syn

arel

Synarel (Nasal Solution) B 5 DL C1

Trelstar

Mixj

ect

Trelstar Mixject (Intramuscular Suspension


A1

Hormonal Agents, Suppressant (Thyroid)B1

Antithyroid AgentsC1

Met

himazol

e

Methimazole (Oral Tablet) G 1 ¨C1

Propylt

hiou

racil

Propylthiouracil (Oral Tablet) G 2 ¨A1

Immunological AgentsB1

Angioedema AgentsC1

Beri

nert

Berinert (Intravenous Kit) B 5 PA; LA; DL C1

Cinr

yze

Cinryze (Intravenous Solution Reconstituted) B 5 PA; LA; DL C1

Haegard

a

Haegarda (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL C1

Icati

bant

Acet

ate Icatibant Acetate (Subcutaneous Solution) G 5 PA; DL; QL C1

Ruc

onest

Ruconest (Intravenous Solution Reconstituted) B 5 PA; LA; DL B1

ImmunoglobulinsC1

BIVIGA

M

BIVIGAM (Intravenous Solution) B 5 PA; DL C1

Fleboga

mma

DIF Flebogamma DIF (5GM/50ML Intravenous Solution) B 5 PA; DL C1

Ga

mm

agard

Gammagard (2.5GM/25ML Injection Solution) B 5 PA; DL C1

Ga

mmagar

d S/D

Less

IgA Gammagard S/D Less IgA (Intravenous Solution


C1

Gamm

ake

d

Gammaked (1GM/10ML Injection Solution) B 5 PA; DL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Gamm

aple

x

Gammaplex (10GM/100ML Intravenous Solution,

10GM/200ML Intravenous Solution, 20GM/200ML

Intravenous Solution, 5GM/50ML Intravenous

Solution)

B 5 PA; DL

C1

Gamun

ex-C

Gamunex-C (1GM/10ML Injection Solution) B 5 PA; DL C1

Oct

aga

m

Octagam (1GM/20ML Intravenous Solution, 2GM/

20ML Intravenous Solution)B 5 PA; DL

C1

Pan

zyga

Panzyga (Intravenous Solution) B 5 PA; DL C1

Privigen

Privigen (20GM/200ML Intravenous Solution) B 5 PA; DL C1

Varizig

Varizig (Intramuscular Solution) B 5 DL B1

Immunological Agents, OtherC1

Acte

mra ACT

Pen

Actemra ACTPen (Subcutaneous Solution Auto-

Injector)B 5 PA; DL

C1

Acte

mra

Actemra (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Arcalyst

Arcalyst (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL C1

Benlysta

Benlysta (Subcutaneous Solution Auto-Injector) B 5 PA; DL C1

Benl

ysta

Benlysta (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Cos

entyx

Cosentyx (300 MG Dose) (Subcutaneous Solution

Prefilled Syringe)B 5 PA; LA; DL

C1

Cosenty

x

Sensore

ady Cosentyx Sensoready (300 MG) (Subcutaneous

Solution Auto-Injector)B 5 PA; LA; DL

C1

Kineret

Kineret (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Ore

ncia

ClickJec

t Orencia ClickJect (Subcutaneous Solution Auto-

Injector)B 5 PA; DL

C1

Ore

ncia

Orencia (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Ote

zla

Otezla (Oral Tablet) B 5 PA; LA; DL C1

Otezla

Otezla (Oral Tablet Therapy Pack) B 5 PA; LA; DL C1

Rida

ura

Ridaura (Oral Capsule) B 5 DL C1

Stel

ara

Stelara (Subcutaneous Solution) B 5 PA; DL C1

Stel

ara

Stelara (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Xeljanz

Xeljanz (Oral Tablet Immediate Release) B 5 PA; DL; QL C1

Xeljanz

XR

Xeljanz XR (Oral Tablet Extended Release 24 Hour) B 5 PA; DL; QL C1

Xola

ir

Xolair (Subcutaneous Solution Prefilled Syringe) B 5 PA; LA; DL C1

Xola

ir

Xolair (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL B1

ImmunostimulantsC1

Actimm

une

Actimmune (Subcutaneous Solution) B 5 LA; DL C1

Intro

n A

Intron A (Injection Solution) B 5 PA; LA; DL C1

Intro

n A

Intron A (Injection Solution Reconstituted) B 5 PA; LA; DL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pegasys

ProClic

k Pegasys ProClick (Subcutaneous Solution) B 5 PA; DL C1

Sylatron

Sylatron (200MCG Subcutaneous Kit, 300MCG

Subcutaneous Kit)B 5 PA; DL

B1

ImmunosuppressantsC1

Azat

hioprine

Azathioprine (Oral Tablet) G 2 B/D, PA ¨C1

Cimzia

Prefi

lled

Cimzia Prefilled (Subcutaneous Kit) B 5 PA; DL C1

Cimzia

Cimzia (Subcutaneous Kit) B 5 PA; DL C1

Cycl

osp

orine

Modified Cyclosporine Modified (Oral Capsule) G 3 B/D, PA C1

Cycl

osporin

e

Modified Cyclosporine Modified (Oral Solution) G 3 B/D, PA C1

Cycl

osporin

e

Cyclosporine (Oral Capsule) G 3 B/D, PA C1

Enbrel

Mini

Enbrel Mini (Subcutaneous Solution Cartridge) B 5 PA; DL C1

Enbrel

Enbrel (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Enb

rel

Enbrel (Subcutaneous Solution Reconstituted) B 5 PA; DL C1

Enb

rel Sure

Click Enbrel SureClick (Subcutaneous Solution Auto-

Injector)B 5 PA; DL

C1

Envarsu

s XR

Envarsus XR (Oral Tablet Extended Release 24 Hour) B 4 B/D, PA C1

Everolim

us

Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet, 0.75MG Oral Tablet)

G 5 B/D, PA; DL C1

Gen

graf

Gengraf (Oral Capsule) G 3 B/D, PA C1

Gen

graf

Gengraf (Oral Solution) G 3 B/D, PA C1

Hu

mira

Pediatric

Cro

hns

Start Humira Pediatric Crohns Start (Subcutaneous

Prefilled Syringe Kit)B 5 PA; DL

C1

Humira

Pen

Humira Pen (Subcutaneous Pen-Injector Kit) B 5 PA; DL C1

Hu

mira

Pen Cro

hns Dise

ase

Starter Humira Pen Crohns Disease Starter (Subcutaneous

Pen-Injector Kit)B 5 PA; DL

C1

Hu

mira Pen

Psor

iasis

Starter Humira Pen Psoriasis Starter (Subcutaneous Pen-

Injector Kit)B 5 PA; DL

C1

Hu

mira

Humira (Subcutaneous Prefilled Syringe Kit) B 5 PA; DL C1

Lefluno

mid

e

Leflunomide (Oral Tablet) G 2 ¨C1

Methotr

exate

Methotrexate (Oral Tablet) G 2 ¨C1

Met

hotr

exate

Sodium Methotrexate Sodium (50MG/2ML Injection Solution

Prefilled Syringe)G 2 ¨

C1

Met

hotrexat

e Sodi

um Methotrexate Sodium (50MG/2ML Injection Solution) G 2 ¨C1

Mycoph

enol

ate Mof

etil Mycophenolate Mofetil (Oral Capsule) G 3 B/D, PA C1

Mycoph

enolate

Mof

etil Mycophenolate Mofetil (Oral Suspension Reconstituted) G 5 B/D, PA; DL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Mycoph

enol

ate Mof

etil Mycophenolate Mofetil (Oral Tablet) G 3 B/D, PA C1

Mycoph

enolate

Sodium Mycophenolate Sodium (Oral Tablet Delayed Release) G 4 B/D, PA C1

Pro

graf

Prograf (Oral Packet) B 4 B/D, PA C1

Ras

uvo

Rasuvo (Subcutaneous Solution Auto-Injector) B 4 PA C1

Sandim

mun

e

Sandimmune (Oral Solution) B 5 B/D, PA; DL C1

Simponi

Simponi (Subcutaneous Solution Auto-Injector) B 5 PA; DL C1

Sim

poni

Simponi (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL C1

Sirol

imus

Sirolimus (Oral Solution) G 5 B/D, PA; DL C1

Sirol

imus

Sirolimus (Oral Tablet) G 4 B/D, PA C1

Tacrolim

us

Tacrolimus (Oral Capsule) G 3 B/D, PA C1

Trexall

Trexall (Oral Tablet) G 4

C1

Xat

mep

Xatmep (Oral Solution) B 4 PA C1

Zort

ress

Zortress (1MG Oral Tablet) B 5 B/D, PA; DL B1

VaccinesC1

ActHIB

ActHIB (Intramuscular Solution Reconstituted) B 3 QL C1

Ada

cel

Adacel (Intramuscular Suspension) B 3 QL C1

BC

G Vac

cine

BCG Vaccine (Injection) B 3 QL C1

Bex

sero

Bexsero (Intramuscular Suspension Prefilled Syringe) B 3 QL C1

Boostrix

Boostrix (5-2.5-18.5 Intramuscular Suspension,

5-2.5-18.5 (0.5ML Syringe) Intramuscular

Suspension)

B 3 QL

C1

Dap

tace

l

Daptacel (Intramuscular Suspension) B 3 QL C1

Diph

theria-

Teta

nus Tox

oids DT Diphtheria-Tetanus Toxoids DT (Intramuscular

Suspension)B 3 QL

C1

Eng

erix-B

Engerix-B (Injection Suspension) B 3 B/D, PA; QL C1

Gardasil

9

Gardasil 9 (Intramuscular Suspension) B 3 QL C1

Gardasil

9

Gardasil 9 (Intramuscular Suspension Prefilled

Syringe)B 3 QL

C1

Havr

ix

Havrix (Intramuscular Suspension) B 3 QL C1

Hibe

rix

Hiberix (Injection Solution Reconstituted) B 3 QL C1

Imovax

Rabi

es

Imovax Rabies (Intramuscular Injectable) B 3 B/D, PA; QL C1

Infanrix

Infanrix (Intramuscular Suspension) B 3 QL C1

IPO

L

IPOL (Injection) B 3 QL C1

Ixiar

o

Ixiaro (Intramuscular Suspension) B 3 QL C1

Kinri

x

Kinrix (Intramuscular Suspension) B 3 QL C1

Menactr

a

Menactra (Intramuscular Injectable) B 3 QL C1

Menveo

Menveo (Intramuscular Solution Reconstituted) B 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

M-M-R

II

M-M-R II (Injection Solution Reconstituted) B 3 QL C1

Pediarix

Pediarix (Intramuscular Suspension) B 3 QL C1

Ped

vax

HIB

Pedvax HIB (Intramuscular Suspension) B 3 QL C1

Pro

Quad

ProQuad (Subcutaneous Suspension Reconstituted) B 3 QL C1

Quadrac

el

Quadracel (Intramuscular Suspension) B 3 QL C1

RabAver

t

RabAvert (Intramuscular Suspension Reconstituted) B 3 B/D, PA; QL C1

Rec

omb

ivax HB

Recombivax HB (Injection Suspension) B 3 B/D, PA; QL C1

Rot

arix

Rotarix (Oral Suspension Reconstituted) B 3 QL C1

Rot

aTeq

RotaTeq (Oral Solution) B 3 QL C1

Shingrix

Shingrix (Intramuscular Suspension Reconstituted) B 3 PA; QL C1

TDVAX

TDVAX (Intramuscular Suspension) B 3 QL C1

Teni

vac

Tenivac (Intramuscular Injectable) B 3 QL C1

Tru

menba

Trumenba (Intramuscular Suspension Prefilled

Syringe)B 3 QL

C1

Twinrix

Twinrix (Intramuscular Suspension Prefilled Syringe) B 3 QL C1

Typhim

Vi

Typhim Vi (Intramuscular Solution) B 3 QL C1

VAQ

TA

VAQTA (Intramuscular Suspension) B 3 QL C1

Vari

vax

Varivax (Subcutaneous Injectable) B 3 QL C1

YF-

Vax

YF-Vax (Subcutaneous Injectable) B 3 QL C1

Zostavax

Zostavax (19400UNT/0.65ML Subcutaneous

Suspension Reconstituted)B 4 PA; QL

A1

Inflammatory Bowel Disease AgentsB1

AminosalicylatesC1

Apri

so

Apriso (Oral Capsule Extended Release 24 Hour) B 3 QL C1

Balsalazi

de

Disodiu

m Balsalazide Disodium (Oral Capsule) G 4

C1

Dipentu

m

Dipentum (Oral Capsule) B 5 DL C1

Mes

ala

mine

ER Mesalamine ER (0.375MG Oral Capsule Extended

Release 24 Hour) (Generic Apriso)G 3 QL

C1

Mes

alamin

e

Mesalamine (1.2GM Oral Tablet Delayed Release)

(Generic Lialda)G 3 QL

C1

Mesala

min

e

Mesalamine (Rectal Enema) G 4 QL C1

Mesala

mine

Mesalamine (Rectal Suppository) G 4 QL C1

Pent

asa

Pentasa (Oral Capsule Extended Release) B 4 QL C1

Sulf

asalazin

e

Sulfasalazine (Oral Tablet Immediate Release) G 2 ¨




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Sulfasal

azin

e

Sulfasalazine (Oral Tablet Delayed Release) G 2 ¨B1

GlucocorticoidsC1

Bud

eso

nide ER

Budesonide ER (Oral Tablet Extended Release 24 Hour) G 5 ST; DL C1

Bud

esonide

Budesonide (Oral Capsule Delayed Release Particles) G 4

C1

Hydroco

rtiso

ne

Hydrocortisone (Rectal Enema) G 4

C1

Procto-

Med HC

Procto-Med HC (External Cream) G 2 ¨C1

Proc

to-

Pak

Procto-Pak (External Cream) G 2 ¨C1

Proc

tosol HC

Proctosol HC (External Cream) G 2 ¨C1

Proc

tozone-

HC

Proctozone-HC (External Cream) G 2 ¨A1

Metabolic Bone Disease AgentsB1

Metabolic Bone Disease AgentsC1

Alen

dronate

Sodi

um Alendronate Sodium (Oral Solution) G 4

C1

Alen

dronate

Sodium Alendronate Sodium (10MG Oral Tablet, 35MG Oral

Tablet, 70MG Oral Tablet)G 1 QL ¨

C1

Calcitoni

n

Salmon Calcitonin Salmon (Nasal Solution) G 3 QL C1

Calcitriol

Calcitriol (Oral Capsule) G 2 B/D, PA ¨C1

Calc

itriol

Calcitriol (Oral Solution) G 2 B/D, PA ¨C1

Cina

calcet

HCl

Cinacalcet HCl (30MG Oral Tablet) G 4 B/D, PA; QL C1

Cina

calcet

HCl

Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet) G 5 B/D, PA; DL; QL C1

Doxerca

lciferol

Doxercalciferol (Oral Capsule) G 4 B/D, PA C1

Fort

eo

Forteo (Subcutaneous Solution Pen-Injector) B 5 PA; DL; QL C1

Iban

dronate

Sodi

um Ibandronate Sodium (Oral Tablet) G 2 QL ¨C1

Nat

para

Natpara (Subcutaneous Cartridge) B 5 PA; LA; DL C1

Paricalci

tol

Paricalcitol (Oral Capsule) G 4 B/D, PA C1

Prolia

Prolia (Subcutaneous Solution Prefilled Syringe) B 4 QL C1

Ray

alde

e

Rayaldee (Oral Capsule Extended Release) B 5 DL; QL C1

Rise

dronate

Sodium Risedronate Sodium (Oral Tablet Immediate Release) G 3 QL C1

Teripara

tide

Teriparatide (Recombinant) (Subcutaneous Solution

Pen-Injector)B 5 PA; DL; QL

C1

Tymlos

Tymlos (Subcutaneous Solution Pen-Injector) B 5 PA; DL; QL C1

Xge

va

Xgeva (Subcutaneous Solution) B 5 PA; DL A1

Miscellaneous Therapeutic AgentsB1

Miscellaneous Therapeutic AgentsC1

Alcohol

Pre

p Pad

s Alcohol Prep Pads G 3

C1

Gauze

Gauze (Non-medicated 2X2 Pad) G 3

C1

Insul

in Syri

nge

s, Nee

dles Insulin Syringes, Needles G 3

A1

Ophthalmic Agents


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

B1

Ophthalmic Agents, OtherC1

Atropine

Sulf

ate Atropine Sulfate (1% Ophthalmic Solution) B 3

C1

Neo

myci

n-Poly

myxin-

Bacitraci

n-

Hydroco

rtisone

Neomycin-Polymyxin-Bacitracin-Hydrocortisone

(Ophthalmic Ointment)G 3

C1

Blep

hamide

Blephamide (Ophthalmic Suspension) B 4

C1

Blepham

ide

S.O.P. Blephamide S.O.P. (Ophthalmic Ointment) G 4

C1

Combi

gan

Combigan (Ophthalmic Solution) B 3

C1

Cyst

aran

Cystaran (Ophthalmic Solution) B 5 LA; DL C1

Dor

zolamid

e

HCl-Tim

olol Mal

eate Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution) G 2 ¨C1

Dor

zolamid

e HCl-

Timolol

Mal

eate

Preserva

tive

Free

Dorzolamide HCl-Timolol Maleate Preservative Free

(Ophthalmic Solution)G 4

C1

Lacrisert

Lacrisert (Ophthalmic Insert) B 4

C1

Neomyci

n-Poly

myxin-

Dex

amethas

oneNeomycin-Polymyxin-Dexamethasone (Ophthalmic

Ointment)G 2 ¨

C1

Neo

mycin-

Poly

myxin-

Dexame

thas

oneNeomycin-Polymyxin-Dexamethasone (3.5-10000-0.1 Ophthalmic Suspension)

G 2 ¨C1

Neo

mycin-

Polymyxi

n-

HC Neomycin-Polymyxin-HC (Ophthalmic Suspension) G 4

C1

Pred-G

Pred-G (Ophthalmic Suspension) B 4

C1

Pred-G

S.O.P.

Pred-G S.O.P. (Ophthalmic Ointment) B 4

C1

Pro

para

caine

HCl Proparacaine HCl (Ophthalmic Solution) G 2 ¨C1

Rest

asis Sing

le-

Use Vials Restasis Single-Use Vials (Ophthalmic Emulsion) B 3 QL C1

Roc

klatan

Rocklatan (Ophthalmic Solution) B 3 ST C1

Sulfacet

amide-

Pre

dnisolon

e Sulfacetamide-Prednisolone (Ophthalmic Solution) G 2 ¨C1

Tob

raD

ex

TobraDex (Ophthalmic Ointment) B 3

C1

Tob

raDex

ST

TobraDex ST (Ophthalmic Suspension) B 4

C1

Tob

ramycin-

Dexame

thas

one Tobramycin-Dexamethasone (Ophthalmic Suspension) G 3

C1

Xiidra

Xiidra (Ophthalmic Solution) B 4 QL B1

Ophthalmic Anti-allergy AgentsC1

Aloc

ril

Alocril (Ophthalmic Solution) B 4

C1

Alo

mide

Alomide (Ophthalmic Solution) B 4

C1

Azelastin

e

HCl

Azelastine HCl (Ophthalmic Solution) G 3

C1

Bepreve

Bepreve (Ophthalmic Solution) B 4

C1

Cro

mol

yn Sodi

um Cromolyn Sodium (Ophthalmic Solution) G 2 ¨C1

Epin

astine

HCl

Epinastine HCl (Ophthalmic Solution) G 3

C1

Last

acaft

Lastacaft (Ophthalmic Solution) B 3




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Olopata

dine

HCl

Olopatadine HCl (Ophthalmic Solution) G 3

C1

Pazeo

Pazeo (Ophthalmic Solution) B 3

B1

Ophthalmic Anti-InfectivesC1

Baci

tracin

Bacitracin (Ophthalmic Ointment) G 2 ¨C1

Bacitraci

n-

Polymyxi

n B Bacitracin-Polymyxin B (Ophthalmic Ointment) G 2 ¨C1

Besivanc

e

Besivance (Ophthalmic Suspension) B 4

C1

Cilo

xan

Ciloxan (Ophthalmic Ointment) B 4

C1

Cipr

ofloxaci

n

HCl Ciprofloxacin HCl (Ophthalmic Solution) G 2 ¨C1

Eryt

hromyci

n

Erythromycin (Ophthalmic Ointment) G 2 ¨C1

Gatifloxa

cin

Gatifloxacin (Ophthalmic Solution) G 3

C1

Gentak

Gentak (Ophthalmic Ointment) G 2 ¨C1

Gen

tamicin

Sulf

ate Gentamicin Sulfate (Ophthalmic Solution) G 2 ¨C1

Lev

ofloxaci

n

Levofloxacin (0.5% Ophthalmic Solution) G 3

C1

Moxiflox

acin

HCl

Moxifloxacin HCl (Ophthalmic Solution) (Generic Vigamox)

G 4

C1

Natacyn

Natacyn (Ophthalmic Suspension) B 4

C1

Neo

myci

n-Baci

tracin-

Polymyxi

n Neomycin-Bacitracin-Polymyxin (5-400-10000

Ophthalmic Ointment)G 3

C1

Neo

mycin-

Poly

myxin-

Gramici

din Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution) G 3

C1

Oflo

xacin

Ofloxacin (Ophthalmic Solution) G 2 ¨C1

Polymyxi

n B-Trim

etho

prim Polymyxin B-Trimethoprim (Ophthalmic Solution) G 2 ¨C1

Sulf

acet

amide

Sodium Sulfacetamide Sodium (Ophthalmic Ointment) G 2 ¨C1

Sulf

acetami

de

Sodium Sulfacetamide Sodium (Ophthalmic Solution) G 2 ¨C1

Tob

ramycin

Tobramycin (Ophthalmic Solution) G 2 ¨C1

Tobrex

Tobrex (Ophthalmic Ointment) B 4

C1

Trifluridi

ne

Trifluridine (Ophthalmic Solution) G 3

B1

Ophthalmic Anti-inflammatoriesC1

Dex

amethas

one Sodi

um

Phosph

ate Dexamethasone Sodium Phosphate (Ophthalmic Solution)

G 2 ¨C1

Diclofen

ac

Sodium Diclofenac Sodium (Ophthalmic Solution) G 2 ¨C1

Flarex

Flarex (Ophthalmic Suspension) B 4

C1

Fluo

rom

etholone

Fluorometholone (Ophthalmic Suspension) G 3

C1

Flur

biprofen

Sodium Flurbiprofen Sodium (Ophthalmic Solution) G 2 ¨C1

FML

Forte

FML Forte (Ophthalmic Suspension) B 4

C1

FML

FML (Ophthalmic Ointment) B 4

C1

Ilevro

Ilevro (Ophthalmic Suspension) B 3

C1

Ket

orolac

Tro

metham

ine Ketorolac Tromethamine (Ophthalmic Solution) G 3


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Lotemax

Lotemax (Ophthalmic Gel) B 4

C1

Lotemax

Lotemax (Ophthalmic Ointment) B 4

C1

Lote

max

Lotemax (Ophthalmic Suspension) B 4

C1

Lote

max SM

Lotemax SM (Ophthalmic Gel) B 4

C1

Lotepred

nol

Etabonat

e Loteprednol Etabonate (Ophthalmic Suspension) G 4

C1

Pred

Mild

Pred Mild (Ophthalmic Suspension) B 4

C1

Pre

dnis

olone

Acetate Prednisolone Acetate (Ophthalmic Suspension) G 3

C1

Pre

dnisolon

e

Sodium

Phosph

ate Prednisolone Sodium Phosphate (1% Ophthalmic Solution)

G 2 ¨C1

Prol

ensa

Prolensa (Ophthalmic Solution) B 4

B1

Ophthalmic Beta-Adrenergic Blocking AgentsC1

Betaxolo

l HCl

Betaxolol HCl (Ophthalmic Solution) G 3

C1

Beti

mol

Betimol (Ophthalmic Solution) B 4

C1

Cart

eolol

HCl

Carteolol HCl (Ophthalmic Solution) G 2 ¨C1

Levobu

nolo

l HCl Levobunolol HCl (Ophthalmic Solution) G 2 ¨C1

Timolol

Maleate

Ophthal

mic Gel

Formin

g

Timolol Maleate Ophthalmic Gel Forming (Ophthalmic Solution) (Generic Timoptic-XE)

G 3

C1

Tim

olol

Maleate

Timolol Maleate (0.25% Ophthalmic Solution, 0.5%

Ophthalmic Solution) (Generic Timoptic)G 2 ¨

B1

Ophthalmic Intraocular Pressure Lowering Agents, OtherC1

Alph

agan P

Alphagan P (0.1% Ophthalmic Solution) B 3

C1

Apraclo

nidine

HCl Apraclonidine HCl (Ophthalmic Solution) G 3

C1

Azo

pt

Azopt (Ophthalmic Suspension) B 3

C1

Brim

onidine

Tartr

ate Brimonidine Tartrate (0.15% Ophthalmic Solution) B 4

C1

Brim

onidine

Tartrate Brimonidine Tartrate (0.2% Ophthalmic Solution) G 2 ¨C1

Dorzola

mid

e HCl Dorzolamide HCl (Ophthalmic Solution) G 2 ¨C1

Methaz

olamid

e Methazolamide (Oral Tablet) G 4

C1

Pho

sph

oline

Iodide Phospholine Iodide (Ophthalmic Solution

Reconstituted)B 4

C1

Pilo

carpine

HCl

Pilocarpine HCl (Ophthalmic Solution) G 3

C1

Rhopres

sa

Rhopressa (Ophthalmic Solution) B 3 ST C1

Simbrin

za

Simbrinza (Ophthalmic Suspension) B 3

B1

Ophthalmic Prostaglandin and Prostamide AnalogsC1

Lata

noprost

Latanoprost (Ophthalmic Solution) G 1 ¨C1

Lum

igan

Lumigan (Ophthalmic Solution) B 3




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Travopr

ost

Travoprost (BAK Free) (Ophthalmic Solution) G 3

C1

Vyzulta

Vyzulta (Ophthalmic Solution) B 4

A1

Otic AgentsB1

Otic AgentsC1

Acetic

Acid

Acetic Acid (Otic Solution) G 2 ¨C1

Cipro

HC

Cipro HC (Otic Suspension) B 4

C1

Flac

Flac (Otic Oil) G 4

C1

Fluo

cinolone

Acetonid

e Fluocinolone Acetonide (Otic Oil) G 4

C1

Hyd

rocortiso

ne-Acet

ic Acid Hydrocortisone-Acetic Acid (Otic Solution) G 3

C1

Neomyci

n-

Polymyxi

n-HC Neomycin-Polymyxin-HC (1% Otic Solution) G 3

C1

Neomyci

n-Poly

myxin-

HC Neomycin-Polymyxin-HC (Otic Suspension) G 3

C1

Oflo

xacin

Ofloxacin (Otic Solution) G 3

A1

Respiratory Tract/Pulmonary AgentsB1

AntihistaminesC1

Azelastin

e HCl

Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal

Solution)G 3

C1

Azel

astin

e-Fluti

casone Azelastine-Fluticasone (Nasal Suspension) G 4

C1

Ceti

rizine

HCl

Cetirizine HCl (1MG/ML Oral Solution) G 2 ¨C1

Cyp

roheptad

ine HCl Cyproheptadine HCl (Oral Syrup) G 4

C1

Cyprohe

ptadine

HCl Cyproheptadine HCl (Oral Tablet) G 4

C1

Dym

ista

Dymista (Nasal Suspension) B 4

C1

Lev

ocetirizin

e

Dihydroc

hloride Levocetirizine Dihydrochloride (Oral Tablet) G 1 QL ¨

B1

Anti-inflammatories, Inhaled CorticosteroidsC1

Arnuity

Ellip

ta

Arnuity Ellipta (Inhalation Aerosol Powder Breath

Activated)B 3 QL

C1

Budeso

nide

Budesonide (Inhalation Suspension) G 4 B/D, PA C1

Flov

ent

Diskus

Flovent Diskus (Inhalation Aerosol Powder Breath

Activated)B 3 QL

C1

Flov

ent HFA

Flovent HFA (Inhalation Aerosol) B 3 QL C1

Flunisoli

de

Flunisolide (Nasal Solution) G 1 ¨C1

Fluticas

one Pro

pion

ate Fluticasone Propionate (Nasal Suspension) G 2 ¨C1

Mo

met

asone

Furoate Mometasone Furoate (Nasal Suspension) G 4

B1

AntileukotrienesC1

Mon

telukast

Sodium Montelukast Sodium (Oral Packet) G 2 QL ¨C1

Montelu

kast

Sodium Montelukast Sodium (Oral Tablet) G 1 QL ¨C1

Montelu

kast Sodi

um Montelukast Sodium (Oral Tablet Chewable) G 2 QL ¨C1

Zafir

lukast

Zafirlukast (Oral Tablet) G 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Zileuton

ER

Zileuton ER (Oral Tablet Extended Release 12 Hour) G 5 ST; DL C1

Zyflo

Zyflo (Oral Tablet Immediate Release) B 5 ST; DL B1

Bronchodilators, AnticholinergicC1

Atro

vent

HFA

Atrovent HFA (Inhalation Aerosol Solution) B 4

C1

Incruse

Ellip

ta

Incruse Ellipta (Inhalation Aerosol Powder Breath

Activated)B 3 QL

C1

Ipratropi

um Bro

mid

e Ipratropium Bromide (Inhalation Solution) G 2 B/D, PA ¨C1

Iprat

ropi

um Bro

mide Ipratropium Bromide (Nasal Solution) G 2 ¨C1

Lon

hala Mag

nair

Lonhala Magnair (Inhalation Solution) B 5 DL; QL C1

Spiri

va Han

diHaler Spiriva HandiHaler (Inhalation Capsule) B 3 QL C1

Spiriva

Res

pimat Spiriva Respimat (Inhalation Aerosol Solution) B 3 QL

B1

Bronchodilators, SympathomimeticC1

Albu

terol

Sulf

ate HFA Albuterol Sulfate HFA (108 (90 Base)MCG/ACT

Inhalation Aerosol Solution (Generic Proair), 108 (90 Base)MCG/ACT Inhalation Aerosol Solution) (Generic

Proventil)

G 2 ¨

C1

Albu

terol

Sulfate Albuterol Sulfate (Inhalation Nebulization Solution) G 2 B/D, PA ¨C1

Albuterol

Sulfate Albuterol Sulfate (Oral Syrup) G 4

C1

Albuterol

Sulf

ate Albuterol Sulfate (Oral Tablet Immediate Release) G 4

C1

Epin

ephr

ine

Epinephrine (Injection Solution Auto-Injector) G 3 QL C1

Lev

albuterol

HCl

Levalbuterol HCl (Inhalation Nebulization Solution) G 4 B/D, PA C1

Met

aprotere

nol Sulf

ate Metaproterenol Sulfate (Oral Syrup) G 4

C1

Perforo

mist

Perforomist (Inhalation Nebulization Solution) B 4 B/D, PA; QL C1

Pro

Air

HFA

ProAir HFA (Inhalation Aerosol Solution) B 3

C1

Pro

Air Res

piCli

ck ProAir RespiClick (Inhalation Aerosol Powder Breath

Activated)B 3

C1

Sere

vent

Diskus Serevent Diskus (Inhalation Aerosol Powder Breath

Activated)B 3 QL

B1

Cystic Fibrosis AgentsC1

Bethkis

Bethkis (Inhalation Nebulization Solution) B 5 B/D, PA; DL; QL C1

Cay

ston

Cayston (Inhalation Solution Reconstituted) B 5 PA; LA; DL C1

Kaly

deco

Kalydeco (Oral Packet) B 5 PA; LA; DL; QL C1

Kalydec

o

Kalydeco (Oral Tablet) B 5 PA; LA; DL; QL C1

Orkamb

i

Orkambi (Oral Packet) B 5 PA; LA; DL; QL C1

Ork

amb

i

Orkambi (Oral Tablet) B 5 PA; LA; DL; QL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Pulmoz

yme

Pulmozyme (Inhalation Solution) B 5 B/D, PA; DL; QL C1

TOBI

Podhale

r TOBI Podhaler (Inhalation Capsule) B 5 PA; DL; QL C1

Tob

ram

ycin

Tobramycin (Inhalation Nebulization Solution) G 5 B/D, PA; DL; QL B1

Mast Cell StabilizersC1

Cromol

yn

Sodium Cromolyn Sodium (Inhalation Nebulization Solution) G 5 B/D, PA; DL

B1

Phosphodiesterase Inhibitors, Airways DiseaseC1

Dalir

esp

Daliresp (Oral Tablet) B 4 PA; QL C1

The

ophyllin

e

ER Theophylline ER (300MG Oral Tablet Extended Release 12 Hour)

G 2 ¨C1

The

ophyllin

e ER Theophylline ER (Oral Tablet Extended Release 24 Hour) G 2 ¨C1

Theoph

yllin

e

Theophylline (Oral Solution) G 2 ¨B1

Pulmonary AntihypertensivesC1

Ade

mpas

Adempas (Oral Tablet) B 5 PA; LA; DL C1

Alyq

Alyq (Oral Tablet) G 4 PA; QL C1

Ambris

enta

n

Ambrisentan (Oral Tablet) G 5 PA; LA; DL; QL C1

Bosenta

n

Bosentan (Oral Tablet) G 5 PA; LA; DL; QL C1

Ops

umit

Opsumit (Oral Tablet) B 5 PA; LA; DL C1

Ore

nitram

Orenitram (0.125MG Oral Tablet Extended Release) B 4 PA; LA C1

Ore

nitram

Orenitram (0.25MG Oral Tablet Extended Release,

1MG Oral Tablet Extended Release, 2.5MG Oral

Tablet Extended Release, 5MG Oral Tablet Extended

Release)

B 5 PA; LA; DL

C1

Sildenaf

il Citra

te Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio) G 3 PA; QL C1

Tad

alafil

Tadalafil (PAH) (20MG Oral Tablet) G 4 PA; QL C1

Trac

leer

Tracleer (Oral Tablet Soluble) B 5 PA; LA; DL; QL C1

Vent

avis

Ventavis (Inhalation Solution) B 5 PA; LA; DL; QL B1

Pulmonary Fibrosis AgentsC1

Esbriet

Esbriet (Oral Capsule) B 5 PA; LA; DL; QL C1

Esbr

iet

Esbriet (Oral Tablet) B 5 PA; LA; DL; QL C1

Ofe

v

Ofev (Oral Capsule) B 5 PA; LA; DL; QL B1

Respiratory Tract Agents, OtherC1

Acetylcy

steine

Acetylcysteine (Inhalation Solution) G 2 B/D, PA ¨C1

Adv

air

Diskus

Advair Diskus (Inhalation Aerosol Powder Breath

Activated)B 3 QL

C1

Adv

air HFA

Advair HFA (Inhalation Aerosol) B 3 QL C1

Ano

ro Ellip

ta

Anoro Ellipta (Inhalation Aerosol Powder Breath

Activated)B 3 QL

C1

Bevespi

Aerosp

here Bevespi Aerosphere (Inhalation Aerosol) B 3 QL


Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Breo

Ellip

ta

Breo Ellipta (Inhalation Aerosol Powder Breath

Activated)B 3 QL

C1

Combi

vent

Respim

at Combivent Respimat (Inhalation Aerosol Solution) B 3 QL C1

Dule

ra

Dulera (Inhalation Aerosol) B 4 QL C1

Fas

enra Pen

Fasenra Pen (Subcutaneous Solution Auto-Injector) B 5 PA; LA; DL C1

Fasenra

Fasenra (Subcutaneous Solution Prefilled Syringe) B 5 PA; LA; DL C1

Fluticas

one-Sal

met

erol Fluticasone-Salmeterol (Inhalation Aerosol Powder Breath Activated)

G 3 QL C1

Iprat

ropi

um-Albu

terol Ipratropium-Albuterol (Inhalation Solution) G 1 B/D, PA ¨C1

Nuc

ala

Nucala (Subcutaneous Solution Auto-Injector) B 5 PA; LA; DL; QL C1

Nuc

ala

Nucala (Subcutaneous Solution Prefilled Syringe) B 5 PA; LA; DL; QL C1

Nucala

Nucala (Subcutaneous Solution Reconstituted) B 5 PA; LA; DL; QL C1

Stiolto

Respim

at Stiolto Respimat (Inhalation Aerosol Solution) B 3 QL C1

Sym

bicort

Symbicort (Inhalation Aerosol) B 3 QL C1

Trel

egy Ellip

ta

Trelegy Ellipta (Inhalation Aerosol Powder Breath

Activated)B 3 QL

C1

Wixela

Inhu

b

Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)

G 3 QL

A1

Skeletal Muscle RelaxantsB1

Skeletal Muscle RelaxantsC1

Chlo

rzoxazo

ne

Chlorzoxazone (500MG Oral Tablet) G 3

C1

Cycl

obenza

prine

HCl Cyclobenzaprine HCl (10MG Oral Tablet, 5MG Oral Tablet)

G 2 ¨C1

Cyclobe

nzaprin

e

HCl Cyclobenzaprine HCl (7.5MG Oral Tablet) G 4

A1

Sleep Disorder AgentsB1

Sleep Promoting AgentsC1

Bels

omra

Belsomra (Oral Tablet) B 3 QL C1

Hetlioz

Hetlioz (Oral Capsule) B 5 PA; LA; DL; QL C1

Ramelte

on

Ramelteon (Oral Tablet) G 4 QL C1

Tem

aze

pam

Temazepam (15MG Oral Capsule, 30MG Oral Capsule) G 2 QL ¨C1

Zale

plon

Zaleplon (Oral Capsule) G 3 QL C1

Zolpide

m

Tartrate Zolpidem Tartrate (Oral Tablet Immediate Release) G 2 QL ¨

B1

Wakefulness Promoting AgentsC1

Arm

odaf

inil

Armodafinil (Oral Tablet) G 4 PA; QL C1

Mod

afinil

Modafinil (Oral Tablet) G 3 PA; QL




Drug Name

Brand

or

Generic

Drug

Tier

Coverage Rules

or Limits on use

C1

Xyrem

Xyrem (Oral Solution) B 5 PA; LA; DL; QL


Covered drugs with a quantity limit (QL)

This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each

strength may have a different quantity limit. If quantity limits for a drug vary by strength, the

different strengths are listed on separate lines. These limits may be in place to ensure your safety.

Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain

number of days. For more information about quantity limits, talk with your doctor or pharmacist.

You can also call Customer Service. Our contact information is on the cover.

Drugs are listed in alphabetical order in the chart below. Brand name drugs in bold type (for

example, Humalog) and generic drugs in plain type (for example, Simvastatin).

Drug Name

Brand

or

Generic

Quantity Limit

Abacavir Sulfate (Oral Solution) G Maximum of 32 ml per day

Abacavir Sulfate (Oral Tablet) G Maximum of 2 tablets per day

Abacavir Sulfate-Lamivudine (Oral Tablet) G Maximum of 1 tablet per day

Abacavir-Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Abiraterone Acetate (Oral Tablet) G Maximum of 4 tablets per day

Acarbose (100MG Oral Tablet) G Maximum of 3 tablets per day



Acetaminophen-Codeine (120-12MG/5ML

Oral Solution)G Maximum of 150 ml per day

Acetaminophen-Codeine (300-15MG Oral

Tablet, 300-30MG Oral Tablet, 300-60MG

Oral Tablet)

G Maximum of 13 tablets per day

ActHIB (Intramuscular Solution

Reconstituted)B

1 vaccination dose (1 injection) per

day

Acyclovir (External Ointment) GMaximum of 1 tube (30 grams) per 30

days

Adacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Advair Diskus (Inhalation Aerosol Powder

Breath Activated)B

Maximum of 1 inhaler (60 blisters) per

30 days

Advair HFA (Inhalation Aerosol) BMaximum of 1 inhaler (12 grams) per

30 days

Aimovig (140MG/ML Subcutaneous

Solution Auto-Injector)B Maximum of 1 pen (1 ml) per 30 days

Aimovig (70MG/ML Subcutaneous Solution

Auto-Injector)B

Maximum of 2 pens (2 ml) per 30

days

Albendazole (Oral Tablet) G Maximum of 16 tablets per day

Alecensa (Oral Capsule) B Maximum of 8 capsules per day

Alendronate Sodium (10MG Oral Tablet) G Maximum of 1 tablet per day

102

Drug Name

Brand

or

Generic

Quantity Limit

Alendronate Sodium (35MG Oral Tablet) G Maximum of 8 tablets per 28 days

Alendronate Sodium (70MG Oral Tablet) G Maximum of 4 tablets per 28 days

Aliskiren Fumarate (Oral Tablet) G Maximum of 1 tablet per day

Alprazolam (0.25MG Oral Tablet Immediate

Release, 0.5MG Oral Tablet Immediate

Release, 1MG Oral Tablet Immediate

Release)


Alprazolam (2MG Oral Tablet Immediate

Release)G Maximum of 5 tablets per day

Alunbrig (180MG Oral Tablet, 90MG Oral

Tablet)B Maximum of 1 tablet per day

Alunbrig (30MG Oral Tablet) B Maximum of 4 tablets per day

Alunbrig (Oral Tablet Therapy Pack) BMaximum of 1 pack (30 tablets) per

30 days

Alyq (Oral Tablet) G Maximum of 2 tablets per day

Ambrisentan (Oral Tablet) G Maximum of 1 tablet per day

Amitiza (Oral Capsule) B Maximum of 2 capsules per day

Amlodipine-Atorvastatin (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Benazepril (Oral Capsule) G Maximum of 1 capsule per day

Amlodipine-Olmesartan (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Valsartan (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Valsartan-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Amphetamine-Dextroamphetamine ER (Oral

Capsule Extended Release 24 Hour)G Maximum of 2 capsules per day

Amphetamine-Dextroamphetamine (10MG

Oral Tablet, 12.5MG Oral Tablet, 15MG Oral

Tablet, 30MG Oral Tablet, 5MG Oral Tablet,

7.5MG Oral Tablet)


Amphetamine-Dextroamphetamine (20MG

Oral Tablet)G Maximum of 3 tablets per day

Androderm (Transdermal Patch 24 Hour) B Maximum of 1 patch per day

Anoro Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Apokyn (Subcutaneous Solution Cartridge) B Maximum of 3 ml per day

Apriso (Oral Capsule Extended Release 24

Hour)B Maximum of 4 capsules per day

Aptiom (200MG Oral Tablet, 400MG Oral


Aptiom (600MG Oral Tablet, 800MG Oral

Tablet)B Maximum of 2 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Aptivus (Oral Capsule) B Maximum of 4 capsules per day

Aptivus (Oral Solution) BMaximum of 4 bottles (380 ml) per 30

days

Aripiprazole (1MG/ML Oral Solution) G Maximum of 25 ml per day

Aripiprazole (10MG Oral Tablet, 15MG Oral


30MG Oral Tablet, 5MG Oral Tablet)

G Maximum of 1 tablet per day

Aripiprazole ODT (10MG Oral Tablet

Dispersible)G Maximum of 3 tablets per day

Aripiprazole ODT (15MG Oral Tablet


Armodafinil (150MG Oral Tablet, 200MG Oral

Tablet, 250MG Oral Tablet)G Maximum of 1 tablet per day

Armodafinil (50MG Oral Tablet) G Maximum of 2 tablets per day

Arnuity Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Aspirin-Dipyridamole ER (Oral Capsule

Extended Release 12 Hour)G Maximum of 2 capsules per day

Atazanavir Sulfate (150MG Oral Capsule,

300MG Oral Capsule)G Maximum of 1 capsule per day

Atazanavir Sulfate (200MG Oral Capsule) G Maximum of 2 capsules per day

Atomoxetine HCl (100MG Oral Capsule,

60MG Oral Capsule, 80MG Oral Capsule)G Maximum of 1 capsule per day

Atomoxetine HCl (10MG Oral Capsule, 18MG

Oral Capsule, 25MG Oral Capsule, 40MG

Oral Capsule)

G Maximum of 2 capsules per day

Atorvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day

Atripla (Oral Tablet) B Maximum of 1 tablet per day

Aubagio (Oral Tablet) B Maximum of 1 tablet per day

Austedo (Oral Tablet) B Maximum of 4 tablets per day

Avonex Pen (Intramuscular Auto-Injector

Kit)B Maximum of 1 kit per 28 days

Avonex Prefilled (Intramuscular Prefilled

Syringe Kit)B Maximum of 1 kit per 28 days

Ayvakit (Oral Tablet) B Maximum of 1 tablet per day

Balversa (3MG Oral Tablet) B Maximum of 3 tablets per day

Balversa (4MG Oral Tablet) B Maximum of 2 tablets per day

Balversa (5MG Oral Tablet) B Maximum of 1 tablet per day

BCG Vaccine (Injection) B 1 vaccination dose (1 vial) per day

Belsomra (Oral Tablet) B Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Benazepril HCl (Oral Tablet) G Maximum of 2 tablets per day

Benazepril-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Betaseron (Subcutaneous Kit) BMaximum of 1 kit (15 vials) per 30

days

Bethkis (Inhalation Nebulization Solution) B Maximum of 2 ampules (8 ml) per day

Bevespi Aerosphere (Inhalation Aerosol) BMaximum of 1 inhaler (10.7 grams)

per 30 days

Bexsero (Intramuscular Suspension

Prefilled Syringe)B 1 vaccination dose (0.5 ml) per day

BiDil (Oral Tablet) B Maximum of 6 tablets per day

Biktarvy (Oral Tablet) B Maximum of 1 tablet per day

Bisoprolol-Hydrochlorothiazide (Oral Tablet) G Maximum of 2 tablets per day

Boostrix (5-2.5-18.5 Intramuscular

Suspension, 5-2.5-18.5 (0.5ML Syringe)

Intramuscular Suspension)

B 1 vaccination dose (0.5 ml) per day

Bosentan (Oral Tablet) G Maximum of 2 tablets per day

Bosulif (100MG Oral Tablet) B Maximum of 6 tablets per day

Bosulif (400MG Oral Tablet, 500MG Oral


Breo Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Brilinta (Oral Tablet) B Maximum of 2 tablets per day

BRIVIACT (10MG/ML Oral Solution) B Maximum of 20 ml per day

BRIVIACT (100MG Oral Tablet, 10MG Oral

Tablet, 25MG Oral Tablet, 50MG Oral

Tablet, 75MG Oral Tablet)

B Maximum of 2 tablets per day

Brukinsa (Oral Capsule) B Maximum of 4 capsules per day

Buprenorphine HCl (Tablet Sublingual) G Maximum of 3 tablets per day

Buprenorphine HCl-Naloxone HCl (12-3MG

Sublingual Film, 4-1MG Sublingual Film)G Maximum of 2 films per day

Buprenorphine HCl-Naloxone HCl (2-0.5MG

Sublingual Film, 8-2MG Sublingual Film)G Maximum of 3 films per day

Buprenorphine HCl-Naloxone HCl (Tablet

Sublingual)G Maximum of 3 tablets per day

Buprenorphine (Transdermal Patch Weekly) G Maximum of 4 patches per 28 days

Butalbital-Acetaminophen-Caffeine (Oral

Tablet)G Maximum of 6 tablets per day

Butalbital-Aspirin-Caffeine (Oral Capsule) G Maximum of 6 capsules per day

Butorphanol Tartrate (Nasal Solution) GMaximum of 2 bottles (5 ml) per 30

days


Drug Name

Brand

or

Generic

Quantity Limit

Bydureon BCise (Subcutaneous Auto-

Injector)B

Maximum of 4 pens (3.4 ml) per 28

days

Bydureon (Subcutaneous Pen-Injector) B Maximum of 4 pens per 28 days

Byetta 10MCG Pen (Subcutaneous Solution

Pen-Injector)B

Maximum of 1 pen (2.4 ml) per 30

days

Byetta 5MCG Pen (Subcutaneous Solution

Pen-Injector)B


days

Bystolic (10MG Oral Tablet, 2.5MG Oral

Tablet, 5MG Oral Tablet)B Maximum of 1 tablet per day

Bystolic (20MG Oral Tablet) B Maximum of 2 tablets per day

Cablivi (Injection Kit) B Maximum of 1 kit per day

Cabometyx (20MG Oral Tablet, 60MG Oral


Cabometyx (40MG Oral Tablet) B Maximum of 2 tablets per day

Calcitonin Salmon (Nasal Solution) G Maximum of 1 bottle per 28 days

Calquence (Oral Capsule) B Maximum of 2 capsules per day

Candesartan Cilexetil (16MG Oral Tablet,

32MG Oral Tablet, 4MG Oral Tablet)G Maximum of 1 tablet per day

Candesartan Cilexetil (8MG Oral Tablet) G Maximum of 3 tablets per day

Candesartan Cilexetil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Caplyta (Oral Capsule) B Maximum of 1 capsule per day

Captopril (100MG Oral Tablet) G Maximum of 4 tablets per day

Captopril (12.5MG Oral Tablet, 25MG Oral


Captopril (50MG Oral Tablet) G Maximum of 9 tablets per day

Captopril-Hydrochlorothiazide (25-15MG Oral

Tablet, 50-15MG Oral Tablet)G Maximum of 3 tablets per day

Captopril-Hydrochlorothiazide (25-25MG Oral


Celecoxib (Oral Capsule) G Maximum of 2 capsules per day

Chloroquine Phosphate (Oral Tablet) G Maximum of 2 tablets per day

Cimduo (Oral Tablet) B Maximum of 1 tablet per day

Cinacalcet HCl (30MG Oral Tablet, 60MG


Cinacalcet HCl (90MG Oral Tablet) G Maximum of 4 tablets per day

Clindamycin Phosphate (External Gel) G Maximum of 75 grams per 30 days

Clobazam (2.5MG/ML Oral Suspension) G Maximum of 16 ml per day

Clobazam (10MG Oral Tablet, 20MG Oral



Drug Name

Brand

or

Generic

Quantity Limit

Clonazepam (0.5MG Oral Tablet, 1MG Oral


Clonazepam (2MG Oral Tablet) G Maximum of 10 tablets per day

Clonazepam ODT (0.125MG Oral Tablet

Dispersible, 0.25MG Oral Tablet Dispersible,

0.5MG Oral Tablet Dispersible, 1MG Oral

Tablet Dispersible)


Clonazepam ODT (2MG Oral Tablet


Clopidogrel Bisulfate (75MG Oral Tablet) G Maximum of 4 tablets per day

Clorazepate Dipotassium (15MG Oral Tablet) G Maximum of 6 tablets per day

Clorazepate Dipotassium (3.75MG Oral


Clorazepate Dipotassium (7.5MG Oral Tablet) G Maximum of 12 tablets per day

Clovique (Oral Capsule) G Maximum of 8 capsules per day

Clozapine ODT (100MG Oral Tablet


Clozapine ODT (12.5MG Oral Tablet








Codeine Sulfate (15MG Oral Tablet) B Maximum of 6 tablets per day

Codeine Sulfate (30MG Oral Tablet, 60MG


Colchicine (0.6MG Oral Capsule) (Brand

Equivalent Mitigare)B Maximum of 4 capsules per day

Colchicine (0.6MG Oral Tablet) (Generic

Colcrys)G Maximum of 4 tablets per day

Combivent Respimat (Inhalation Aerosol

Solution)B

Maximum of 1 inhaler (4 grams) per

20 days

Complera (Oral Tablet) B Maximum of 1 tablet per day

Copiktra (Oral Capsule) B Maximum of 2 capsules per day

Corlanor (Oral Solution) B Maximum of 15 ml per day

Corlanor (Oral Tablet) B Maximum of 2 tablets per day

Cotellic (Oral Tablet) B Maximum of 3 tablets per day

Crixivan (200MG Oral Capsule) B Maximum of 9 capsules per day


Drug Name

Brand

or

Generic

Quantity Limit

Crixivan (400MG Oral Capsule) B Maximum of 6 capsules per day

Cycloset (Oral Tablet) B Maximum of 6 tablets per day

Dalfampridine ER (Oral Tablet Extended

Release 12 Hour)G Maximum of 2 tablets per day

Daliresp (Oral Tablet) B Maximum of 1 tablet per day

Daptacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Daurismo (100MG Oral Tablet) B Maximum of 1 tablet per day

Daurismo (25MG Oral Tablet) B Maximum of 2 tablets per day

Delstrigo (Oral Tablet) B Maximum of 1 tablet per day

Descovy (Oral Tablet) B Maximum of 1 tablet per day

Desoximetasone (External Cream) G Maximum of 100 grams per 30 days

Desvenlafaxine Succinate ER (100MG Oral

Tablet Extended Release 24 Hour) (Generic

Pristiq)


Desvenlafaxine Succinate ER (25MG Oral

Tablet Extended Release 24 Hour, 50MG Oral

Tablet Extended Release 24 Hour) (Generic

Pristiq)


Dexilant (Oral Capsule Delayed Release) B Maximum of 1 capsule per day

Dexmethylphenidate HCl (Oral Tablet) G Maximum of 2 tablets per day

Dextroamphetamine Sulfate ER (10MG Oral






Dextroamphetamine Sulfate (Oral Tablet) G Maximum of 6 tablets per day

Diazepam Intensol (5MG/ML Oral

Concentrate)G Maximum of 8 ml per day

Diazepam (10MG Oral Tablet, 2MG Oral

Tablet, 5MG Oral Tablet)G Maximum of 4 tablets per day

Diazepam (10MG Rectal Gel, 2.5MG Rectal

Gel, 20MG Rectal Gel)G Maximum of 5 packages per 30 days

Diclofenac Epolamine (Transdermal Patch) G Maximum of 2 patches per day

Didanosine (250MG Oral Capsule Delayed

Release, 400MG Oral Capsule Delayed

Release)

G Maximum of 1 capsule per day

Dihydroergotamine Mesylate (Nasal Solution) GMaximum of 16 vials (16 ml) per 28

days


Drug Name

Brand

or

Generic

Quantity Limit

Diphtheria-Tetanus Toxoids DT

(Intramuscular Suspension)B 1 vaccination dose (0.5 ml) per day

Donepezil HCl (10MG Oral Tablet) G Maximum of 2 tablets per day

Donepezil HCl (23MG Oral Tablet, 5MG Oral

Tablet)G Maximum of 1 tablet per day

Donepezil HCl ODT (10MG Oral Tablet


Donepezil HCl ODT (5MG Oral Tablet

Dispersible)G Maximum of 1 tablet per day

Dovato (Oral Tablet) B Maximum of 1 tablet per day

Doxepin HCl (External Cream) G Maximum of 90 grams per 30 days

Drizalma Sprinkle (20MG Oral Capsule

Delayed Release Sprinkle, 30MG Oral

Capsule Delayed Release Sprinkle, 60MG

Oral Capsule Delayed Release Sprinkle)

B Maximum of 2 capsules per day

Drizalma Sprinkle (40MG Oral Capsule

Delayed Release Sprinkle)B Maximum of 3 capsules per day

Dulera (120 Inhalation Aerosol) BMaximum of 1 inhaler (13 grams) per

30 days

Duloxetine HCl (20MG Oral Capsule Delayed

Release Particles, 30MG Oral Capsule

Delayed Release Particles, 60MG Oral

Capsule Delayed Release Particles)


Dutasteride (Oral Capsule) G Maximum of 1 capsule per day

Econazole Nitrate (External Cream) G Maximum of 90 grams per 30 days

Edarbi (Oral Tablet) B Maximum of 1 tablet per day

Edarbyclor (Oral Tablet) B Maximum of 1 tablet per day

Edurant (Oral Tablet) B Maximum of 1 tablet per day

Efavirenz (Oral Capsule) G Maximum of 3 capsules per day

Efavirenz (Oral Tablet) G Maximum of 1 tablet per day

Eliquis Starter Pack (Oral Tablet) BMaximum of 1 pack (74 tablets) per

30 days

Eliquis (Oral Tablet) B Maximum of 2 tablets per day

Emgality (300MG Dose) (100MG/ML

Subcutaneous Solution Prefilled Syringe)B

Maximum of 3 syringes or pens (3 ml)

per 30 days

Emgality (Subcutaneous Solution Auto-

Injector)B


per 30 days

Emgality (120MG/ML Subcutaneous

Solution Prefilled Syringe)B


per 30 days

Emsam (Transdermal Patch 24 Hour) B Maximum of 1 patch per day


Drug Name

Brand

or

Generic

Quantity Limit

Emtriva (Oral Capsule) B Maximum of 1 capsule per day

Emtriva (Oral Solution) BMaximum of 5 bottles (850 ml) per 30

days

Enalapril Maleate (Oral Tablet) G Maximum of 2 tablets per day

Enalapril-Hydrochlorothiazide (10-25MG Oral


Enalapril-Hydrochlorothiazide (5-12.5MG Oral


Endocet (10-325MG Oral Tablet, 5-325MG

Oral Tablet, 7.5-325MG Oral Tablet)G Maximum of 12 tablets per day

Engerix-B (10MCG/0.5ML Injection

Suspension)B 1 vaccination dose (0.5 ml) per day

Engerix-B (20MCG/ML Injection

Suspension)B 1 vaccination dose (1 ml) per day

Enoxaparin Sodium (100MG/ML

Subcutaneous Solution, 150MG/ML

Subcutaneous Solution)

G Maximum of 2 syringes (2 ml) per day

Enoxaparin Sodium (120MG/0.8ML

Subcutaneous Solution, 80MG/0.8ML

Subcutaneous Solution)

GMaximum of 2 syringes (1.6 ml) per

day


Subcutaneous Solution)G

Maximum of 2 syringes (0.6 ml) per

day




day




day

Entresto (Oral Tablet) B Maximum of 2 tablets per day

Epclusa (Oral Tablet) B Maximum of 1 tablet per day

Epinephrine (Injection Solution Auto-Injector) GMaximum of 4 pens (2 boxes) per 30

days

Erivedge (Oral Capsule) B Maximum of 1 capsule per day

Erleada (Oral Tablet) B Maximum of 4 tablets per day

Erlotinib HCl (100MG Oral Tablet, 150MG

Oral Tablet)G Maximum of 1 tablet per day

Erlotinib HCl (25MG Oral Tablet) G Maximum of 3 tablets per day

Esbriet (Oral Capsule) B Maximum of 9 capsules per day

Esbriet (267MG Oral Tablet) B Maximum of 9 tablets per day

Esbriet (801MG Oral Tablet) B Maximum of 3 tablets per day

Esomeprazole Magnesium (20MG Oral

Capsule Delayed Release) (Generic Nexium)G Maximum of 3 capsules per day


Drug Name

Brand

or

Generic

Quantity Limit

Esomeprazole Magnesium (40MG Oral

Capsule Delayed Release) (Generic Nexium)G Maximum of 2 capsules per day

Estradiol (Transdermal Patch Weekly) G Maximum of 4 patches per 28 days

Estradiol (Vaginal Tablet) G Maximum of 1 tablet per day

Evotaz (Oral Tablet) B Maximum of 1 tablet per day

Ezetimibe (Oral Tablet) G Maximum of 1 tablet per day

Ezetimibe-Simvastatin (Oral Tablet) G Maximum of 1 tablet per day

Famciclovir (125MG Oral Tablet, 250MG Oral


Famciclovir (500MG Oral Tablet) G Maximum of 3 tablets per day

Fanapt (10MG Oral Tablet, 12MG Oral


4MG Oral Tablet, 6MG Oral Tablet, 8MG

Oral Tablet)


Farxiga (Oral Tablet) B Maximum of 1 tablet per day

Fentanyl Citrate (Buccal Lozenge On A

Handle)G Maximum of 4 lozenges per day

Fentanyl (100MCG/HR Transdermal Patch 72

Hour, 12MCG/HR Transdermal Patch 72




Hour)

G Maximum of 15 patches per 30 days

Fetzima (Oral Capsule Extended Release

24 Hour)B Maximum of 1 capsule per day

Flovent Diskus (Inhalation Aerosol Powder

Breath Activated)B

Maximum of 2 inhalers (120 blisters)

per 30 days

Flovent HFA (110MCG/ACT Inhalation

Aerosol)B


30 days


Aerosol)B

Maximum of 2 inhalers (24 grams)

per 30 days


Aerosol)B

Maximum of 1 inhaler (10.6 grams)

per 30 days

Fluticasone-Salmeterol (100-50MCG/DOSE

Inhalation Aerosol Powder Breath Activated,

250-50MCG/DOSE Inhalation Aerosol

Powder Breath Activated, 500-50MCG/DOSE

Inhalation Aerosol Powder Breath Activated)

(Generic Advair)

GMaximum of 1 inhaler (60 blisters) per

30 days


Drug Name

Brand

or

Generic

Quantity Limit

Fluticasone-Salmeterol (113-14MCG/ACT

Inhalation Aerosol Powder Breath Activated,

232-14MCG/ACT Inhalation Aerosol Powder

Breath Activated, 55-14MCG/ACT Inhalation

Aerosol Powder Breath Activated) (Brand

Equivalent AirDuo)

G Maximum of 1 inhaler per 30 days

Fluvastatin Sodium (20MG Oral Capsule) G Maximum of 1 capsule per day

Fluvastatin Sodium (40MG Oral Capsule) G Maximum of 2 capsules per day

Forteo (Subcutaneous Solution Pen-

Injector)B


days

Fosamprenavir Calcium (Oral Tablet) G Maximum of 4 tablets per day

Fosinopril Sodium (Oral Tablet) G Maximum of 2 tablets per day

Fosinopril Sodium-HCTZ (Oral Tablet) G Maximum of 4 tablets per day

Fuzeon (Subcutaneous Solution

Reconstituted)B Maximum of 2 vials per day

Fycompa (Oral Suspension) B Maximum of 24 ml per day

Fycompa (Oral Tablet) B Maximum of 1 tablet per day

Galantamine Hydrobromide ER (Oral Capsule

Extended Release 24 Hour)G Maximum of 1 capsule per day

Galantamine Hydrobromide (Oral Solution) GMaximum of 2 bottles (200 ml) per 30

days

Galantamine Hydrobromide (Oral Tablet) G Maximum of 2 tablets per day

Gardasil 9 (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Gardasil 9 (Intramuscular Suspension


Genvoya (Oral Tablet) B Maximum of 1 tablet per day

Gilenya (0.5MG Oral Capsule) BMaximum of 1 pack (30 capsules) per

30 days

Glatiramer Acetate (20MG/ML Subcutaneous

Solution Prefilled Syringe)G Maximum of 1 syringe (1 ml) per day

Glatiramer Acetate (40MG/ML Subcutaneous

Solution Prefilled Syringe)G

Maximum of 12 syringes (12 ml) per

28 days

Glatopa (20MG/ML Subcutaneous Solution

Prefilled Syringe)G Maximum of 1 syringe (1 ml) per day

Glatopa (40MG/ML Subcutaneous Solution

Prefilled Syringe)G

Maximum of 12 syringes (12 ml) per

28 days

Glimepiride (1MG Oral Tablet) G Maximum of 8 tablets per day




Drug Name

Brand

or

Generic

Quantity Limit

Glipizide ER (10MG Oral Tablet Extended


Glipizide ER (2.5MG Oral Tablet Extended


Glipizide ER (5MG Oral Tablet Extended


Glipizide (10MG Oral Tablet Immediate


Glipizide (5MG Oral Tablet Immediate


Glipizide-Metformin HCl (2.5-250MG Oral


Glipizide-Metformin HCl (2.5-500MG Oral


Glyxambi (Oral Tablet) B Maximum of 1 tablet per day

Granisetron HCl (Oral Tablet) G Maximum of 2 tablets per day

Havrix (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime

Hetlioz (Oral Capsule) B Maximum of 1 capsule per day

Hiberix (Injection Solution Reconstituted) B1 vaccination dose (1 injection) per

day

Hydrocodone-Acetaminophen (7.5-325MG/

15ML Oral Solution)G Maximum of 180 ml per day

Hydrocodone-Acetaminophen (10-325MG

Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG

Oral Tablet)


Hydrocodone-Ibuprofen (7.5-200MG Oral


Hydromorphone HCl ER (Oral Tablet ER 24

Hour Abuse-Deterrent)G Maximum of 2 tablets per day

Hydromorphone HCl (1MG/ML Oral Liquid) G Maximum of 50 ml per day

Hydromorphone HCl (2MG Oral Tablet

Immediate Release, 4MG Oral Tablet

Immediate Release)


Hydromorphone HCl (8MG Oral Tablet

Immediate Release)G Maximum of 6 tablets per day

Hydroxychloroquine Sulfate (Oral Tablet) G Maximum of 3 tablets per day

Ibandronate Sodium (Oral Tablet) G Maximum of 1 tablet per 28 days

Ibrance (Oral Capsule) B Maximum of 1 capsule per day

Ibrance (Oral Tablet) B Maximum of 1 tablet per day

Icatibant Acetate (Subcutaneous Solution) G Maximum of 3 syringes (9 ml) per day


Drug Name

Brand

or

Generic

Quantity Limit

Iclusig (15MG Oral Tablet) B Maximum of 2 tablets per day

Iclusig (45MG Oral Tablet) B Maximum of 1 tablet per day

IDHIFA (Oral Tablet) B Maximum of 1 tablet per day

Imatinib Mesylate (Oral Tablet) G Maximum of 3 tablets per day

Imbruvica (140MG Oral Capsule) B Maximum of 4 capsules per day

Imbruvica (70MG Oral Capsule) B Maximum of 1 capsule per day

Imbruvica (Oral Tablet) B Maximum of 1 tablet per day

Imiquimod (5% External Cream) G Maximum of 24 grams per 30 days

Imovax Rabies (Intramuscular Injectable) B1 vaccination dose (1 injection) per

day

Imvexxy Maintenance Pack (Vaginal Insert) B Maximum of 1 vaginal insert per day

Imvexxy Starter Pack (Vaginal Insert) B Maximum of 1 vaginal insert per day

Incruse Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Infanrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Ingrezza (Oral Capsule) B Maximum of 1 capsule per day

Ingrezza (Oral Capsule Therapy Pack) BMaximum of 1 pack (28 capsules) per

28 days

Inlyta (Oral Tablet) B Maximum of 4 tablets per day

Inrebic (Oral Capsule) B Maximum of 4 capsules per day

Intelence (100MG Oral Tablet, 200MG Oral


Intelence (25MG Oral Tablet) B Maximum of 4 tablets per day

Invirase (Oral Tablet) B Maximum of 4 tablets per day

IPOL (Injection) B 1 vaccination dose (0.5 ml) per day

Irbesartan (150MG Oral Tablet, 300MG Oral


Irbesartan (75MG Oral Tablet) G Maximum of 3 tablets per day

Irbesartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Iressa (Oral Tablet) B Maximum of 2 tablets per day

Isentress HD (Oral Tablet) B Maximum of 2 tablets per day

Isentress (Oral Packet) B Maximum of 2 packets per day

Isentress (Oral Tablet) B Maximum of 2 tablets per day

Isentress (Oral Tablet Chewable) B Maximum of 6 tablets per day

Itraconazole (Oral Capsule) G Maximum of 4 capsules per day

Ixiaro (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Jakafi (Oral Tablet) B Maximum of 2 tablets per day

Janumet (Oral Tablet Immediate Release) B Maximum of 2 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Janumet XR (100-1000MG Oral Tablet

Extended Release 24 Hour)B Maximum of 1 tablet per day

Janumet XR (50-1000MG Oral Tablet

Extended Release 24 Hour, 50-500MG Oral

Tablet Extended Release 24 Hour)


Januvia (Oral Tablet) B Maximum of 1 tablet per day

Jardiance (Oral Tablet) B Maximum of 1 tablet per day

Jentadueto (Oral Tablet Immediate

Release)B Maximum of 2 tablets per day

Jentadueto XR (2.5-1000MG Oral Tablet

Extended Release 24 Hour)B Maximum of 2 tablets per day

Jentadueto XR (5-1000MG Oral Tablet

Extended Release 24 Hour)B Maximum of 1 tablet per day

Juluca (Oral Tablet) B Maximum of 1 tablet per day

Kaletra (100-25MG Oral Tablet) B Maximum of 8 tablets per day

Kaletra (200-50MG Oral Tablet) B Maximum of 4 tablets per day

Kalydeco (Oral Packet) B Maximum of 2 packets per day

Kalydeco (Oral Tablet) B Maximum of 2 tablets per day

Ketoconazole (External Cream) G Maximum of 90 grams per 30 days

Kinrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Kisqali (200MG Dose) (Oral Tablet) B Maximum of 3 tablets per day



Kisqali Femara (400MG Dose) (Oral Tablet

Therapy Pack)B

Maximum of 1 pack (91 tablets) per

28 days


Therapy Pack)B


28 days


Therapy Pack)B


28 days

Korlym (Oral Tablet) B Maximum of 4 tablets per day

Koselugo (10MG Oral Capsule) B Maximum of 8 capsules per day

Koselugo (25MG Oral Capsule) B Maximum of 4 capsules per day

Lamivudine (10MG/ML Oral Solution) G Maximum of 32 ml per day

Lamivudine (150MG Oral Tablet) G Maximum of 2 tablets per day

Lamivudine (300MG Oral Tablet) G Maximum of 1 tablet per day

Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Lansoprazole (Oral Capsule Delayed

Release)G Maximum of 2 capsules per day


Drug Name

Brand

or

Generic

Quantity Limit

Latuda (120MG Oral Tablet, 20MG Oral

Tablet, 40MG Oral Tablet, 60MG Oral

Tablet)

B Maximum of 1 tablet per day

Latuda (80MG Oral Tablet) B Maximum of 2 tablets per day

Levocetirizine Dihydrochloride (Oral Tablet) G Maximum of 1 tablet per day

Levorphanol Tartrate (Oral Tablet) G Maximum of 6 tablets per day

Lexiva (Oral Suspension) B Maximum of 60 ml per day

Lidocaine (5% External Ointment) G Maximum of 152 grams per 30 days

Lidocaine (5% External Patch) G Maximum of 3 patches per day

Linezolid (Oral Tablet) G Maximum of 2 tablets per day

Linzess (Oral Capsule) B Maximum of 1 capsule per day

Lisinopril (Oral Tablet) G Maximum of 2 tablets per day

Lisinopril-Hydrochlorothiazide (10-12.5MG


Lisinopril-Hydrochlorothiazide (20-12.5MG


Lisinopril-Hydrochlorothiazide (20-25MG Oral


Livalo (Oral Tablet) B Maximum of 1 tablet per day

Lokelma (Oral Packet) B Maximum of 90 packets per 30 days

Lonhala Magnair (Inhalation Solution) B Maximum of 2 vials (2 ml) per day

Lonsurf (15-6.14MG Oral Tablet) B Maximum of 10 tablets per day

Lonsurf (20-8.19MG Oral Tablet) B Maximum of 8 tablets per day

Lopinavir-Ritonavir (Oral Solution) GMaximum of 2 bottles (320 ml) per 30

days

Lorazepam Intensol (Oral Concentrate) G Maximum of 5 ml per day

Lorazepam (0.5MG Oral Tablet, 1MG Oral


Lorazepam (2MG Oral Tablet) G Maximum of 5 tablets per day

Lorbrena (100MG Oral Tablet) B Maximum of 1 tablet per day

Lorbrena (25MG Oral Tablet) B Maximum of 3 tablets per day

Lorcet HD (Oral Tablet) G Maximum of 12 tablets per day

Lorcet (Oral Tablet) G Maximum of 12 tablets per day

Lorcet Plus (7.5-325MG Oral Tablet) G Maximum of 12 tablets per day

Losartan Potassium (100MG Oral Tablet) G Maximum of 1 tablet per day

Losartan Potassium (25MG Oral Tablet,

50MG Oral Tablet)G Maximum of 2 tablets per day

Losartan Potassium-HCTZ (100-12.5MG Oral

Tablet, 100-25MG Oral Tablet)G Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Losartan Potassium-HCTZ (50-12.5MG Oral


Lovastatin (10MG Oral Tablet, 20MG Oral


Lovastatin (40MG Oral Tablet) G Maximum of 2 tablets per day

Lynparza (Oral Tablet) B Maximum of 4 tablets per day

Mavyret (Oral Tablet) B Maximum of 3 tablets per day

Mayzent (0.25MG Oral Tablet) B Maximum of 8 tablets per day

Mayzent (2MG Oral Tablet) B Maximum of 1 tablet per day

Memantine HCl ER (Oral Capsule Extended

Release 24 Hour)G Maximum of 1 capsule per day

Memantine HCl (2MG/ML Oral Solution) G Maximum of 10 ml per day

Memantine HCl (10MG Oral Tablet) G Maximum of 2 tablets per day

Memantine HCl (5MG Oral Tablet) G Maximum of 3 tablets per day

Menactra (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day

Menveo (Intramuscular Solution

Reconstituted)B


day

Mesalamine ER (0.375MG Oral Capsule

Extended Release 24 Hour) (Generic Apriso)G Maximum of 4 capsules per day

Mesalamine (1.2GM Oral Tablet Delayed

Release) (Generic Lialda)G Maximum of 4 tablets per day

Mesalamine (Rectal Enema) G Maximum of 1 bottle (60 ml) per day

Mesalamine (Rectal Suppository) G Maximum of 1 suppository per day

Metformin HCl ER (500MG Oral Tablet

Extended Release 24 Hour) (Generic

Glucophage XR)


Metformin HCl ER (750MG Oral Tablet

Extended Release 24 Hour) (Generic

Glucophage XR)


Metformin HCl (500MG/5ML Oral Solution) G Maximum of 25.5 ml per day

Metformin HCl (1000MG Oral Tablet

Immediate Release)G Maximum of 2.5 tablets per day





Methadone HCl (10MG/5ML Oral Solution) G Maximum of 60 ml per day

Methadone HCl (5MG/5ML Oral Solution) G Maximum of 120 ml per day

Methadone HCl (10MG Oral Tablet) G Maximum of 12 tablets per day


Drug Name

Brand

or

Generic

Quantity Limit

Methadone HCl (5MG Oral Tablet) G Maximum of 8 tablets per day

Methylphenidate HCl ER (10MG Oral Tablet

Extended Release)G Maximum of 4 tablets per day

Methylphenidate HCl ER (20MG Oral Tablet

Extended Release)G Maximum of 3 tablets per day

Methylphenidate HCl (10MG/5ML Oral

Solution)G Maximum of 30 ml per day

Methylphenidate HCl (5MG/5ML Oral

Solution)G Maximum of 60 ml per day

Methylphenidate HCl (Oral Tablet Immediate

Release) (Generic Ritalin)G Maximum of 3 tablets per day

Miglitol (100MG Oral Tablet) G Maximum of 3 tablets per day



M-M-R II (Injection Solution Reconstituted) B1 vaccination dose (1 injection) per

day

Modafinil (100MG Oral Tablet) G Maximum of 1 tablet per day

Modafinil (200MG Oral Tablet) G Maximum of 2 tablets per day

Moexipril HCl (Oral Tablet) G Maximum of 2 tablets per day

Montelukast Sodium (Oral Packet) G Maximum of 1 packet per day

Montelukast Sodium (Oral Tablet) G Maximum of 1 tablet per day

Montelukast Sodium (Oral Tablet Chewable) G Maximum of 1 tablet per day

Morphine Sulfate (100MG/5ML Oral Solution) G Maximum of 10 ml per day

Morphine Sulfate ER (100MG Oral Tablet

Extended Release, 15MG Oral Tablet

Extended Release) (Generic MS Contin)



Extended Release) (Generic MS Contin)G Maximum of 2 tablets per day


Extended Release, 60MG Oral Tablet

Extended Release) (Generic MS Contin)




Morphine Sulfate (15MG Oral Tablet


Morphine Sulfate (30MG Oral Tablet


Multaq (Oral Tablet) B Maximum of 2 tablets per day

Mupirocin (External Ointment) G Maximum of 110 grams per 30 days


Drug Name

Brand

or

Generic

Quantity Limit

Namzaric (Oral Capsule ER 24 Hour

Therapy Pack)B Maximum of 1 capsule per day

Namzaric (Oral Capsule Extended Release

24 Hour)B Maximum of 1 capsule per day

Naratriptan HCl (Oral Tablet) G Maximum of 12 tablets per 30 days

Nateglinide (120MG Oral Tablet) G Maximum of 3 tablets per day

Nateglinide (60MG Oral Tablet) G Maximum of 6 tablets per day

Nayzilam (Nasal Solution) B Maximum of 10 devices per 30 days

Nerlynx (Oral Tablet) B Maximum of 6 tablets per day

Nevirapine ER (100MG Oral Tablet Extended


Nevirapine ER (400MG Oral Tablet Extended

Release 24 Hour)G Maximum of 1 tablet per day

Nevirapine (Oral Suspension) G Maximum of 40 ml per day

Nevirapine (Oral Tablet Immediate Release) G Maximum of 2 tablets per day

Nifedipine ER (Oral Tablet Extended Release

24 Hour)G Maximum of 2 tablets per day

Nifedipine ER Osmotic Release (Oral Tablet

Extended Release 24 Hour)G Maximum of 2 tablets per day

Ninlaro (Oral Capsule) B Maximum of 3 capsules per 28 days

Northera (100MG Oral Capsule) B Maximum of 3 capsules per day

Northera (200MG Oral Capsule, 300MG

Oral Capsule)B Maximum of 6 capsules per day

Norvir (Oral Packet) B Maximum of 12 packets per day

Norvir (Oral Solution) B Maximum of 16 ml per day

Noxafil (Oral Suspension) B Maximum of 20 ml per day

Nubeqa (Oral Tablet) B Maximum of 4 tablets per day

Nucala (Subcutaneous Solution Auto-

Injector)B Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution Prefilled

Syringe)B Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution

Reconstituted)B Maximum of 3 vials per 28 days

Nucynta ER (Oral Tablet Extended Release

12 Hour)B Maximum of 2 tablets per day

Nuedexta (Oral Capsule) B Maximum of 2 capsules per day

Nuplazid (Oral Capsule) B Maximum of 1 capsule per day

Nuplazid (Oral Tablet) B Maximum of 1 tablet per day

Nyamyc (External Powder) G Maximum of 120 grams per 30 days


Drug Name

Brand

or

Generic

Quantity Limit

Nystatin (External Powder) G Maximum of 120 grams per 30 days

Nystop (External Powder) G Maximum of 120 grams per 30 days

Ocaliva (Oral Tablet) B Maximum of 1 tablet per day

Odefsey (Oral Tablet) B Maximum of 1 tablet per day

Odomzo (Oral Capsule) B Maximum of 1 capsule per day

Ofev (Oral Capsule) B Maximum of 2 capsules per day

Olanzapine (10MG Oral Tablet, 15MG Oral

Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet,

5MG Oral Tablet, 7.5MG Oral Tablet)


Olanzapine ODT (10MG Oral Tablet

Dispersible, 15MG Oral Tablet Dispersible,

20MG Oral Tablet Dispersible, 5MG Oral

Tablet Dispersible)


Olmesartan Medoxomil (20MG Oral Tablet,

40MG Oral Tablet)G Maximum of 1 tablet per day

Olmesartan Medoxomil (5MG Oral Tablet) G Maximum of 2 tablets per day

Olmesartan Medoxomil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Olmesartan-Amlodipine-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Omega-3-Acid Ethyl Esters (Oral Capsule)

(Generic Lovaza)G Maximum of 4 capsules per day

Omeprazole (10MG Oral Capsule Delayed

Release)G Maximum of 3 capsules per day

Orkambi (Oral Packet) B Maximum of 56 packets per 28 days

Orkambi (Oral Tablet) B Maximum of 112 tablets per 28 days

Oseltamivir Phosphate (Oral Capsule) G Maximum of 2 capsules per day

Oseltamivir Phosphate (Oral Suspension

Reconstituted)G Maximum of 26 ml per day

Osphena (Oral Tablet) B Maximum of 1 tablet per day

Oxandrolone (10MG Oral Tablet) G Maximum of 2 tablets per day

Oxandrolone (2.5MG Oral Tablet) G Maximum of 4 tablets per day

Oxybutynin Chloride ER (10MG Oral Tablet





Extended Release 24 Hour)G Maximum of 1 tablet per day

Oxycodone HCl (100MG/5ML Oral

Concentrate)G Maximum of 6 ml per day

Oxycodone HCl (5MG/5ML Oral Solution) G Maximum of 130 ml per day


Drug Name

Brand

or

Generic

Quantity Limit

Oxycodone HCl (10MG Oral Tablet


Immediate Release)






Immediate Release)


Oxycodone-Acetaminophen (10-325MG Oral

Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral

Tablet, 7.5-325MG Oral Tablet)


Oxycodone-Aspirin (Oral Tablet) G Maximum of 12 tablets per day

Ozempic (0.25 or 0.5MG/DOSE)

(Subcutaneous Solution Pen-Injector)B


days

Ozempic (1MG/DOSE) (Subcutaneous

Solution Pen-Injector)B


days

Paliperidone ER (1.5MG Oral Tablet

Extended Release 24 Hour, 3MG Oral Tablet

Extended Release 24 Hour, 9MG Oral Tablet

Extended Release 24 Hour)


Paliperidone ER (6MG Oral Tablet Extended


Pantoprazole Sodium (20MG Oral Tablet

Delayed Release)G Maximum of 3 tablets per day

Pantoprazole Sodium (40MG Oral Tablet

Delayed Release)G Maximum of 2 tablets per day

Pediarix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Pedvax HIB (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Pemazyre (Oral Tablet) B Maximum of 1 tablet per day

Pentamidine Isethionate (Inhalation Solution

Reconstituted)G

Maximum of 1 vial (300 mg) per 28

days

Pentasa (250MG Oral Capsule Extended

Release)B Maximum of 12 capsules per day

Pentasa (500MG Oral Capsule Extended

Release)B Maximum of 8 capsules per day

Perforomist (Inhalation Nebulization

Solution)B Maximum of 2 vials (4 ml) per day

Perindopril Erbumine (Oral Tablet) G Maximum of 2 tablets per day

Picato (0.015% External Gel) B Maximum of 3 tubes per 30 days

Picato (0.05% External Gel) B Maximum of 2 tubes per 30 days


Drug Name

Brand

or

Generic

Quantity Limit

Pifeltro (Oral Tablet) B Maximum of 1 tablet per day

Pimecrolimus (External Cream) G Maximum of 100 grams per 30 days

Pioglitazone HCl (15MG Oral Tablet) G Maximum of 3 tablets per day

Pioglitazone HCl (30MG Oral Tablet, 45MG


Pioglitazone HCl-Glimepiride (Oral Tablet) G Maximum of 1 tablet per day

Pioglitazone HCl-Metformin HCl (Oral Tablet) G Maximum of 3 tablets per day

Piqray (200MG Daily Dose) (Oral Tablet

Therapy Pack)B Maximum of 1 tablet per day


Therapy Pack)B Maximum of 2 tablets per day


Therapy Pack)B Maximum of 2 tablets per day

Pomalyst (Oral Capsule) B Maximum of 1 capsule per day

Posaconazole (Oral Tablet Delayed Release) G Maximum of 6 tablets per day

Praluent (Subcutaneous Solution Auto-

Injector)B


days

Prasugrel HCl (Oral Tablet) G Maximum of 1 tablet per day

Pravastatin Sodium (Oral Tablet) G Maximum of 1 tablet per day

Pregabalin (100MG Oral Capsule, 150MG



Oral Capsule)


Pregabalin (225MG Oral Capsule, 300MG

Oral Capsule)G Maximum of 2 capsules per day

Pregabalin (Oral Solution) G Maximum of 30 ml per day

Premarin (Oral Tablet) B Maximum of 1 tablet per day

Premphase (Oral Tablet) B Maximum of 1 tablet per day

Prempro (Oral Tablet) B Maximum of 1 tablet per day

Prezcobix (Oral Tablet) B Maximum of 1 tablet per day

Prezista (Oral Suspension) BMaximum of 2 bottles (400 ml) per 30

days

Prezista (150MG Oral Tablet) B Maximum of 6 tablets per day

Prezista (600MG Oral Tablet, 75MG Oral


Prezista (800MG Oral Tablet) B Maximum of 1 tablet per day

Prolia (Subcutaneous Solution Prefilled

Syringe)B Maximum of 1 syringe per 180 days

Promacta (Oral Packet) B Maximum of 6 packets per day


Drug Name

Brand

or

Generic

Quantity Limit

Promacta (12.5MG Oral Tablet, 25MG Oral


Promacta (50MG Oral Tablet, 75MG Oral


ProQuad (Subcutaneous Suspension

Reconstituted)B


day

Pulmozyme (Inhalation Solution) B Maximum of 2 ampules (5 ml) per day

Qinlock (Oral Tablet) B Maximum of 3 tablets per day

Quadracel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Quetiapine Fumarate ER (150MG Oral Tablet

Extended Release 24 Hour, 200MG Oral



Quetiapine Fumarate ER (300MG Oral Tablet

Extended Release 24 Hour, 400MG Oral

Tablet Extended Release 24 Hour, 50MG Oral



Quetiapine Fumarate (100MG Oral Tablet



Immediate Release)






Immediate Release)


Quinapril HCl (Oral Tablet) G Maximum of 2 tablets per day

Quinapril-Hydrochlorothiazide (10-12.5MG


Quinapril-Hydrochlorothiazide (20-12.5MG

Oral Tablet, 20-25MG Oral Tablet)G Maximum of 2 tablets per day

RabAvert (Intramuscular Suspension

Reconstituted)B


day

Raloxifene HCl (Oral Tablet) G Maximum of 1 tablet per day

Ramelteon (Oral Tablet) G Maximum of 1 tablet per day

Ramipril (Oral Capsule) G Maximum of 2 capsules per day

Ranolazine ER (Oral Tablet Extended Release

12 Hour)G Maximum of 2 tablets per day

RAVICTI (Oral Liquid) B Maximum of 17.5 ml per day

Rayaldee (Oral Capsule Extended Release) B Maximum of 2 capsules per day


Drug Name

Brand

or

Generic

Quantity Limit

Rebif Rebidose (Subcutaneous Solution

Auto-Injector)B


days

Rebif Rebidose Titration Pack

(Subcutaneous Solution Auto-Injector)B

Maximum of 1 pack (4.2 ml) per 28

days

Rebif (Subcutaneous Solution Prefilled

Syringe)B

Maximum of 12 syringes (6 ml) per 28

days

Rebif Titration Pack (Subcutaneous

Solution Prefilled Syringe)B

Maximum of 1 pack (4.2 ml) per 28

days

Recombivax HB (10MCG/ML Injection

Suspension, 10MCG/ML (1ML Syringe)

Injection Suspension, 40MCG/ML Injection

Suspension)

B 1 vaccination dose (1 ml) per day

Recombivax HB (5MCG/0.5ML Injection

Suspension)B 1 vaccination dose (0.5 ml) per day

Rectiv (Rectal Ointment) B Maximum of 30 grams per 30 days

Relenza Diskhaler (Inhalation Aerosol

Powder Breath Activated)B

Maximum of 3 inhalers (60 blisters)

per 30 days

Relistor (Oral Tablet) B Maximum of 3 tablets per day

Repaglinide (0.5MG Oral Tablet) G Maximum of 32 tablets per day

Repaglinide (1MG Oral Tablet) G Maximum of 16 tablets per day

Repaglinide (2MG Oral Tablet) G Maximum of 8 tablets per day

Repatha Pushtronex System

(Subcutaneous Solution Cartridge)B

Maximum of 1 cartridge (3.5 ml) per

28 days

Repatha (Subcutaneous Solution Prefilled

Syringe)B

Maximum of 3 syringes (3 ml) per 28

days

Repatha SureClick (Subcutaneous Solution

Auto-Injector)B


days

Restasis Single-Use Vials (Ophthalmic

Emulsion)B Maximum of 2 vials per day

Retevmo (40MG Oral Capsule) B Maximum of 6 capsules per day

Retevmo (80MG Oral Capsule) B Maximum of 4 capsules per day

Revlimid (Oral Capsule) B Maximum of 1 capsule per day

Rexulti (Oral Tablet) B Maximum of 1 tablet per day

Reyataz (Oral Packet) B Maximum of 6 packets per day

Riomet ER (Oral Suspension Reconstituted

ER)B Maximum of 20 ml per day

Risedronate Sodium (150MG Oral Tablet

Immediate Release)G Maximum of 1 tablet per 30 days


Drug Name

Brand

or

Generic

Quantity Limit



Immediate Release)



Immediate Release, 35MG (12 PACK) Oral

Tablet Immediate Release, 35MG (4 PACK)

Oral Tablet Immediate Release)

G Maximum of 4 tablets per 28 days

Ritonavir (Oral Tablet) G Maximum of 12 tablets per day

Rivastigmine Tartrate (Oral Capsule) G Maximum of 2 capsules per day

Rivastigmine (Transdermal Patch 24 Hour) G Maximum of 1 patch per day

Rizatriptan Benzoate (Oral Tablet) G Maximum of 12 tablets per 30 days

Rizatriptan Benzoate ODT (Oral Tablet

Dispersible)G Maximum of 12 tablets per 30 days

Rosuvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day

Rotarix (Oral Suspension Reconstituted) B 1 vaccination dose (1 ml) per day

RotaTeq (Oral Solution) B 1 vaccination dose (2 ml) per day

Rozlytrek (100MG Oral Capsule) B Maximum of 5 capsules per day

Rozlytrek (200MG Oral Capsule) B Maximum of 3 capsules per day

Rubraca (Oral Tablet) B Maximum of 4 tablets per day

Rybelsus (Oral Tablet) B Maximum of 1 tablet per day

Rydapt (Oral Capsule) B Maximum of 8 capsules per day

Sancuso (Transdermal Patch) B Maximum of 4 patches per 28 days

Saphris (Tablet Sublingual) B Maximum of 2 tablets per day

Secuado (Transdermal Patch 24 Hour) B Maximum of 1 patch per day

Selzentry (Oral Solution) BMaximum of 8 bottles (1840 ml) per

30 days

Selzentry (150MG Oral Tablet, 75MG Oral


Selzentry (25MG Oral Tablet, 300MG Oral


Serevent Diskus (Inhalation Aerosol

Powder Breath Activated)B

Maximum of 1 inhaler (60 inhalations)

per 30 days

Shingrix (Intramuscular Suspension

Reconstituted)B


day

Sildenafil Citrate (20MG Oral Tablet) (Generic

Revatio)G Maximum of 3 tablets per day

Silodosin (Oral Capsule) G Maximum of 1 capsule per day

Simvastatin (Oral Tablet) G Maximum of 1 tablet per day

Sofosbuvir-Velpatasvir (Oral Tablet) G Maximum of 1 tablet per day


Drug Name

Brand

or

Generic

Quantity Limit

Solifenacin Succinate (Oral Tablet) G Maximum of 1 tablet per day

Soliqua (Subcutaneous Solution Pen-

Injector)B


days

Somavert (Subcutaneous Solution

Reconstituted)B Maximum of 1 vial per day

Sovaldi (150MG Oral Packet) BMaximum of 1 carton (28 packets)

per 28 days

Sovaldi (200MG Oral Packet) BMaximum of 2 cartons (56 packets)

per 28 days

Sovaldi (400MG Oral Tablet) B Maximum of 1 tablet per day

Spiriva HandiHaler (Inhalation Capsule) B Maximum of 1 capsule per day

Spiriva Respimat (Inhalation Aerosol

Solution)B


30 days

Sprycel (100MG Oral Tablet, 140MG Oral


Sprycel (20MG Oral Tablet, 50MG Oral


Sprycel (80MG Oral Tablet) B Maximum of 2 tablets per day

Stavudine (Oral Capsule) G Maximum of 2 capsules per day

Stiolto Respimat (Inhalation Aerosol

Solution)B


30 days

Stivarga (Oral Tablet) B Maximum of 4 tablets per day

Stribild (Oral Tablet) B Maximum of 1 tablet per day

Suboxone (12-3MG Sublingual Film, 4-1MG

Sublingual Film)B Maximum of 2 films per day

Suboxone (2-0.5MG Sublingual Film,

8-2MG Sublingual Film)B Maximum of 3 films per day

Sumatriptan (Nasal Solution) G Maximum of 12 devices per 30 days

Sumatriptan Succinate (100MG Oral Tablet,

25MG Oral Tablet, 50MG Oral Tablet)G Maximum of 12 tablets per 30 days

Sumatriptan Succinate Refill (Subcutaneous

Solution Cartridge)G

Maximum of 12 injections (6 ml) per

30 days

Sumatriptan Succinate (6MG/0.5ML



30 days


Subcutaneous Solution Auto-Injector, 6MG/

0.5ML Subcutaneous Solution Auto-Injector)

GMaximum of 12 injections (6 ml) per

30 days


Subcutaneous Solution Prefilled Syringe)G


30 days


Drug Name

Brand

or

Generic

Quantity Limit

Sutent (12.5MG Oral Capsule, 25MG Oral

Capsule, 50MG Oral Capsule)B Maximum of 1 capsule per day

Sutent (37.5MG Oral Capsule) B Maximum of 2 capsules per day

Symbicort (120 Inhalation Aerosol) BMaximum of 1 inhaler (10.2 grams)

per 30 days

Symfi Lo (Oral Tablet) B Maximum of 1 tablet per day

Symfi (Oral Tablet) B Maximum of 1 tablet per day

Sympazan (Oral Film) B Maximum of 2 films per day

Symtuza (Oral Tablet) B Maximum of 1 tablet per day

Synjardy (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Synjardy XR (10-1000MG Oral Tablet

Extended Release 24 Hour, 25-1000MG

Oral Tablet Extended Release 24 Hour)


Synjardy XR (12.5-1000MG Oral Tablet




Tabrecta (Oral Tablet) B Maximum of 4 tablets per day

Tadalafil (PAH) (20MG Oral Tablet) G Maximum of 2 tablets per day

Tagrisso (Oral Tablet) B Maximum of 1 tablet per day

Talzenna (0.25MG Oral Capsule) B Maximum of 3 capsules per day

Talzenna (1MG Oral Capsule) B Maximum of 1 capsule per day

Targretin (External Gel) B Maximum of 60 grams per 30 days

Tasigna (150MG Oral Capsule) B Maximum of 5 capsules per day



Tazverik (Oral Tablet) B Maximum of 8 tablets per day

TDVAX (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day

Tecfidera (Oral Capsule Delayed Release) B Maximum of 2 capsules per day

Telmisartan (Oral Tablet) G Maximum of 1 tablet per day

Telmisartan-Amlodipine (Oral Tablet) G Maximum of 1 tablet per day

Telmisartan-HCTZ (40-12.5MG Oral Tablet,

80-25MG Oral Tablet)G Maximum of 1 tablet per day

Telmisartan-HCTZ (80-12.5MG Oral Tablet) G Maximum of 2 tablets per day

Temazepam (15MG Oral Capsule, 30MG Oral

Capsule)G Maximum of 1 capsule per day

Tenivac (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day

Tenofovir Disoproxil Fumarate (Oral Tablet) G Maximum of 1 tablet per day

Teriparatide (Recombinant) (Subcutaneous

Solution Pen-Injector)B


days


Drug Name

Brand

or

Generic

Quantity Limit

Tetrabenazine (12.5MG Oral Tablet) G Maximum of 3 tablets per day

Tetrabenazine (25MG Oral Tablet) G Maximum of 4 tablets per day

Thalomid (100MG Oral Capsule, 50MG Oral

Capsule)B Maximum of 1 capsule per day

Thalomid (150MG Oral Capsule, 200MG

Oral Capsule)B Maximum of 2 capsules per day

Tibsovo (Oral Tablet) B Maximum of 2 tablets per day

Tivicay (10MG Oral Tablet, 25MG Oral


Tivicay (50MG Oral Tablet) B Maximum of 2 tablets per day

TOBI Podhaler (Inhalation Capsule) B Maximum of 8 capsules per day

Tobramycin (Inhalation Nebulization Solution) GMaximum of 2 ampules (10 ml) per

day

Tolcapone (Oral Tablet) G Maximum of 6 tablets per day

Tracleer (Oral Tablet Soluble) B Maximum of 8 tablets per day

Tradjenta (Oral Tablet) B Maximum of 1 tablet per day

Tramadol HCl ER (Biphasic) (Oral Tablet

Extended Release 24 Hour)G Maximum of 1 tablet per day

Tramadol HCl ER (Oral Tablet Extended

Release 24 Hour)G Maximum of 1 tablet per day

Tramadol HCl (50MG Oral Tablet Immediate


Tramadol-Acetaminophen (Oral Tablet) G Maximum of 8 tablets per day

Trandolapril (1MG Oral Tablet, 2MG Oral


Trandolapril (4MG Oral Tablet) G Maximum of 2 tablets per day

Trelegy Ellipta (Inhalation Aerosol Powder

Breath Activated)B


30 days

Trientine HCl (Oral Capsule) G Maximum of 8 capsules per day

Trintellix (Oral Tablet) B Maximum of 1 tablet per day

Triumeq (Oral Tablet) B Maximum of 1 tablet per day

Trulicity (Subcutaneous Solution Pen-

Injector)B


days

Trumenba (Intramuscular Suspension


Truvada (Oral Tablet) B Maximum of 1 tablet per day

Tukysa (150MG Oral Tablet) B Maximum of 4 tablets per day

Tukysa (50MG Oral Tablet) B Maximum of 12 tablets per day

Turalio (Oral Capsule) B Maximum of 4 capsules per day


Drug Name

Brand

or

Generic

Quantity Limit

Twinrix (Intramuscular Suspension

Prefilled Syringe)B 1 vaccination dose (1 ml) per day

Tybost (Oral Tablet) B Maximum of 1 tablet per day

Tymlos (Subcutaneous Solution Pen-

Injector)B Maximum of 1.56 ml per 30 days

Typhim Vi (Intramuscular Solution) B 1 vaccination dose (0.5 ml) per day

Valacyclovir HCl (1GM Oral Tablet) G Maximum of 4 tablets per day

Valacyclovir HCl (500MG Oral Tablet) G Maximum of 2 tablets per day

Valchlor (External Gel) B Maximum of 60 grams per 30 days

Valganciclovir HCl (50MG/ML Oral Solution

Reconstituted)G Maximum of 36 ml per day

Valganciclovir HCl (450MG Oral Tablet) G Maximum of 4 tablets per day

Valsartan (160MG Oral Tablet, 40MG Oral

Tablet, 80MG Oral Tablet)G Maximum of 2 tablets per day

Valsartan (320MG Oral Tablet) G Maximum of 1 tablet per day

Valsartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Valtoco 10 MG Dose (Nasal Liquid) BMaximum of 10 blister packs (10

spray devices) per 30 days

Valtoco 15 MG Dose (Nasal Liquid Therapy

Pack)B

Maximum of 10 blister packs (20


Valtoco 20 MG Dose (Nasal Liquid Therapy

Pack)B

Maximum of 10 blister packs (20


Valtoco 5 MG Dose (Nasal Liquid) BMaximum of 10 blister packs (10


Vancomycin HCl (125MG Oral Capsule) G Maximum of 4 capsules per day

Vancomycin HCl (250MG Oral Capsule) G Maximum of 8 capsules per day

VAQTA (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime

Varivax (Subcutaneous Injectable) B1 vaccination dose (1 injection) per

day

Veltassa (Oral Packet) B Maximum of 1 packet per day

Vemlidy (Oral Tablet) B Maximum of 1 tablet per day

Venclexta (100MG Oral Tablet) B Maximum of 6 tablets per day

Venclexta (10MG Oral Tablet) B Maximum of 2 tablets per day

Venclexta (50MG Oral Tablet) B Maximum of 1 tablet per day

Ventavis (10MCG/ML Inhalation Solution) B Maximum of 7 ml per day

Ventavis (20MCG/ML Inhalation Solution) B Maximum of 3 ml per day

Verzenio (Oral Tablet) B Maximum of 2 tablets per day

Victoza (Subcutaneous Solution Pen-

Injector)B


days


Drug Name

Brand

or

Generic

Quantity Limit

Vigabatrin (Oral Packet) G Maximum of 6 packets per day

Vigabatrin (Oral Tablet) G Maximum of 6 tablets per day

Vigadrone (Oral Packet) G Maximum of 6 packets per day

Viibryd (Oral Tablet) B Maximum of 1 tablet per day

Viibryd Starter Pack (Oral Kit) BMaximum of 1 pack (30 tablets) per

30 days

Vimpat (Oral Solution) B Maximum of 40 ml per day

Vimpat (Oral Tablet) B Maximum of 2 tablets per day

Viracept (250MG Oral Tablet) B Maximum of 10 tablets per day

Viracept (625MG Oral Tablet) B Maximum of 4 tablets per day

Viread (Oral Powder) BMaximum of 4 bottles (240 grams)

per 30 days

Viread (150MG Oral Tablet, 200MG Oral


Vitrakvi (100MG Oral Capsule) B Maximum of 4 capsules per day

Vitrakvi (25MG Oral Capsule) B Maximum of 6 capsules per day

Vitrakvi (Oral Solution) B Maximum of 20 ml per day

Vizimpro (Oral Tablet) B Maximum of 1 tablet per day

Vosevi (Oral Tablet) B Maximum of 1 tablet per day

Votrient (Oral Tablet) B Maximum of 4 tablets per day

Vraylar (1.5MG Oral Capsule, 3MG Oral

Capsule, 4.5MG Oral Capsule, 6MG Oral

Capsule)

B Maximum of 1 capsule per day

Vyndamax (Oral Capsule) B Maximum of 1 capsule per day

Vyndaqel (Oral Capsule) B Maximum of 4 capsules per day

Wixela Inhub (Inhalation Aerosol Powder

Breath Activated) (Generic Advair)G


30 days

Xarelto (10MG Oral Tablet, 20MG Oral


Xarelto (15MG Oral Tablet, 2.5MG Oral


Xarelto Starter Pack (Oral Tablet Therapy

Pack)B


30 days

Xcopri (250 MG Daily Dose) (Oral Tablet

Therapy Pack)B


28 days

Xcopri (350 MG Daily Dose) (Oral Tablet

Therapy Pack)B


28 days

Xcopri (100MG Oral Tablet, 50MG Oral



Drug Name

Brand

or

Generic

Quantity Limit

Xcopri (150MG Oral Tablet) B Maximum of 2 tablets per day

Xcopri (200MG Oral Tablet) B Maximum of 2 tablets per day

Xcopri (Oral Tablet Titration Therapy Pack) BMaximum of 1 pack (28 tablets) per

28 days

Xeljanz (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Xeljanz XR (Oral Tablet Extended Release

24 Hour)B Maximum of 1 tablet per day

Xigduo XR (10-1000MG Oral Tablet


Tablet Extended Release 24 Hour,

5-500MG Oral Tablet Extended Release 24

Hour)


Xigduo XR (2.5-1000MG Oral Tablet




Xiidra (Ophthalmic Solution) B Maximum of 2 vials per day

Xofluza (40 MG Dose) (Oral Tablet Therapy

Pack)B Maximum of 2 tablets per 30 days

Xofluza (80 MG Dose) (Oral Tablet Therapy

Pack)B Maximum of 2 tablets per 30 days

Xospata (Oral Tablet) B Maximum of 3 tablets per day

Xpovio (100MG Once Weekly) (Oral Tablet

Therapy Pack)B Maximum of 20 tablets per 28 days





Xpovio (80MG Twice Weekly) (Oral Tablet


Xtampza ER (13.5MG Oral Capsule ER 12

Hour Abuse-Deterrent, 18MG Oral Capsule

ER 12 Hour Abuse-Deterrent, 9MG Oral

Capsule ER 12 Hour Abuse-Deterrent)


Xtampza ER (27MG Oral Capsule ER 12

Hour Abuse-Deterrent, 36MG Oral Capsule

ER 12 Hour Abuse-Deterrent)


Xtandi (Oral Capsule) B Maximum of 4 capsules per day

Xyrem (Oral Solution) B Maximum of 18 ml per day

YF-Vax (Subcutaneous Injectable) B1 vaccination dose (1 injection) per

day


Drug Name

Brand

or

Generic

Quantity Limit

Yuvafem (Vaginal Tablet) G Maximum of 1 tablet per day

Zafirlukast (Oral Tablet) G Maximum of 2 tablets per day

Zaleplon (10MG Oral Capsule) G Maximum of 2 capsules per day

Zaleplon (5MG Oral Capsule) G Maximum of 1 capsule per day

Zejula (Oral Capsule) B Maximum of 3 capsules per day

Zelboraf (Oral Tablet) B Maximum of 8 tablets per day

Zidovudine (Oral Capsule) G Maximum of 6 capsules per day

Zidovudine (Oral Syrup) G Maximum of 64 ml per day

Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Ziprasidone HCl (Oral Capsule) G Maximum of 2 capsules per day

Zolpidem Tartrate (Oral Tablet Immediate

Release)G Maximum of 1 tablet per day

Zostavax (19400UNT/0.65ML

Subcutaneous Suspension Reconstituted)B


day

Zydelig (Oral Tablet) B Maximum of 2 tablets per day

Zykadia (Oral Tablet) B Maximum of 3 tablets per day


Additional covered drugs

Your plan has additional coverage for the prescription drugs listed below. These drugs are not

normally covered in a Medicare Advantage plan with prescription drug coverage. The amount you

pay when you fill prescriptions for these drugs does not count toward your total drug costs. This

means, the amount you pay doesn’t help you qualify for catastrophic coverage. Also, if you’re

receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these

drugs.

Drug Name Drug Tier RestrictionsD1

VitaminsE1

Folic Acid (1mg tablet) 2E1

Cyanocobalamin (1000mcg/ml vial) 2E1

Ergocalciferol (50000mcg capsule) 2D1

Erectile DysfunctionE1

Sildenafil (25mg tablet) 2 Maximum of 4 tablets per 30 daysE1

Sildenafil (50mg tablet) 2 Maximum of 4 tablets per 30 daysE1

Sildenafil (100mg tablet) 2 Maximum of 4 tablets per 30 days

133

Required information

Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change on

January 1 of each year, and from time to time during the plan year. You will receive notice when

necessary.

This information is available for free in other languages. Please call our Customer Service number

located on the cover.

Esta información esta disponible sin costo en otros idiomas. Comuníquese con nuestro número de

Servicio al Cliente situado en la cobertura.

UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws, and does

not discriminate on the basis of race, color, national origin, age, disability, or sex.

134

For more up-to-date information or if you have other questions, please call Customer Service at:

Toll-free 1-800-407-9069, TTY 7118 a.m. - 8 p.m. local time, 7 days a week

www.Medicaplans.com

MDFL21HM4780521_000 Last updated September 1, 2020

Complete Drug List (Formulary) 2021€¦ · (Formulary) 2021 Medica HealthCare Plans MedicareMax...

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